Provider Demographics
NPI:1689626053
Name:DRYDEN FAMILY MEDICINE, PLLC
Entity Type:Organization
Organization Name:DRYDEN FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MASON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SOPCHAK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:607-844-8181
Mailing Address - Street 1:108 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:14903-1318
Mailing Address - Country:US
Mailing Address - Phone:607-734-9539
Mailing Address - Fax:
Practice Address - Street 1:5 EVERGREEN STREET
Practice Address - Street 2:
Practice Address - City:DRYDEN
Practice Address - State:NY
Practice Address - Zip Code:13053
Practice Address - Country:US
Practice Address - Phone:607-844-5251
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03886197Medicaid