Provider Demographics
NPI:1619959590
Name:KOLANCHICK, GARY JOHN (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:JOHN
Last Name:KOLANCHICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1772 HELDERBERG TRL
Mailing Address - Street 2:APT 1
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:518-872-9258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142539207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5385308OtherAETNA
NY308205OtherSENIOR WHOLE HEALTH
NY651047OtherGHI/HMO
NY00714705Medicaid
NY110623000091OtherFIDELIS
NY7D0091OtherEMPIRE BLUECROSS
NY651047OtherGHI/HMO
NY308205OtherSENIOR WHOLE HEALTH
NY7D0091OtherEMPIRE BLUECROSS