1265426423 NPI number — BRYAN S EVANCZYK MD INC PC

Table of content: (NPI 1265426423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265426423 NPI number — BRYAN S EVANCZYK MD INC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRYAN S EVANCZYK MD INC PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1265426423
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 FOX CARE DR
Provider Second Line Business Mailing Address:
STE 303
Provider Business Mailing Address City Name:
ONEONTA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13820-2086
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-432-3711
Provider Business Mailing Address Fax Number:
607-432-6402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 FOX CARE DR
Provider Second Line Business Practice Location Address:
STE 303
Provider Business Practice Location Address City Name:
ONEONTA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13820-2086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-432-3711
Provider Business Practice Location Address Fax Number:
607-432-6402
Provider Enumeration Date:
09/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
EVANCZYK
Authorized Official First Name:
BRYAN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT MEDICAL DIRECTOR
Authorized Official Telephone Number:
607-432-3711

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  1620101 , 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: 00899665 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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