Provider Demographics
NPI:1780673970
Name:GAVRYCK, WAYNE A (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:A
Last Name:GAVRYCK
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 1:8 BURNHAM ST
Mailing Address - Street 2:
Mailing Address - City:TURNERS FALLS
Mailing Address - State:MA
Mailing Address - Zip Code:01376-1816
Mailing Address - Country:US
Mailing Address - Phone:413-774-5554
Mailing Address - Fax:413-775-9137
Practice Address - Street 1:8 BURNHAM ST
Practice Address - Street 2:
Practice Address - City:TURNERS FALLS
Practice Address - State:MA
Practice Address - Zip Code:01376-1816
Practice Address - Country:US
Practice Address - Phone:413-774-5554
Practice Address - Fax:413-775-9137
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA47621207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0138487Medicaid
MAGAN01921Medicare ID - Type UnspecifiedMEDICARE
MA0138487Medicaid