=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902903800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOMACK PRIMARY MEDICAL CARE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 01/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 MONTAUK HWY STE 111
-----------------------------------------------------
City | WEST ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11795-4429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-277-0051
-----------------------------------------------------
Fax | 631-277-2690
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26 RAILROAD AVE # 205
-----------------------------------------------------
City | BABYLON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11702-2204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-277-0051
-----------------------------------------------------
Fax | 631-277-2690
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF MEDICAL OFFICER
-----------------------------------------------------
Name | DR. LAWRENCE H WOMACK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 631-277-0051
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 223075
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------