Provider Demographics
NPI:1205856051
Name:GARY J KOLANCHICK MD PC
Entity Type:Organization
Organization Name:GARY J KOLANCHICK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOLANCHICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-872-9262
Mailing Address - Street 1:1772 HELDERBERG TRL
Mailing Address - Street 2:
Mailing Address - City:BERNE
Mailing Address - State:NY
Mailing Address - Zip Code:12023-2709
Mailing Address - Country:US
Mailing Address - Phone:518-872-9262
Mailing Address - Fax:518-872-9265
Practice Address - Street 1:1772 HELDERBERG TRL
Practice Address - Street 2:
Practice Address - City:BERNE
Practice Address - State:NY
Practice Address - Zip Code:12023-2709
Practice Address - Country:US
Practice Address - Phone:518-872-9262
Practice Address - Fax:518-872-9265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142539207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00714705Medicaid
NY00714705Medicaid
NY55563AMedicare PIN