1619959590 NPI number — GARY JOHN KOLANCHICK M.D.

Table of content: GARY JOHN KOLANCHICK M.D. (NPI 1619959590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619959590 NPI number — GARY JOHN KOLANCHICK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOLANCHICK
Provider First Name:
GARY
Provider Middle Name:
JOHN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619959590
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1772 HELDERBERG TRL
Provider Second Line Business Mailing Address:
APT 1
Provider Business Mailing Address City Name:
BERNE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12023-2709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-872-9262
Provider Business Mailing Address Fax Number:
518-872-9265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1772 HELDERBERG TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERNE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12023-2709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-872-9258
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  142539 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5385308 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 308205 . This is a "SENIOR WHOLE HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 651047 . This is a "GHI/HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00714705 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110623000091 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7D0091 . This is a "EMPIRE BLUECROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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