Provider Demographics
NPI:1265426423
Name:BRYAN S EVANCZYK MD INC PC
Entity type:Organization
Organization Name:BRYAN S EVANCZYK MD INC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:EVANCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-432-3711
Mailing Address - Street 1:1 FOX CARE DR
Mailing Address - Street 2:STE 303
Mailing Address - City:ONEONTA
Mailing Address - State:NY
Mailing Address - Zip Code:13820-2086
Mailing Address - Country:US
Mailing Address - Phone:607-432-3711
Mailing Address - Fax:607-432-6402
Practice Address - Street 1:1 FOX CARE DR
Practice Address - Street 2:STE 303
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-2086
Practice Address - Country:US
Practice Address - Phone:607-432-3711
Practice Address - Fax:607-432-6402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1620101207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00899665Medicaid
NYAA1122Medicare ID - Type Unspecified
NYDD0519Medicare ID - Type Unspecified