Basic Information
| Provider Information | |||||||||
| NPI: | 1205856051 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GARY J KOLANCHICK MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1772 HELDERBERG TRL | ||||||||
| Address2: | |||||||||
| City: | BERNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120232709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188729262 | ||||||||
| FaxNumber: | 5188729265 | ||||||||
| Practice Location | |||||||||
| Address1: | 1772 HELDERBERG TRL | ||||||||
| Address2: | |||||||||
| City: | BERNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120232709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188729262 | ||||||||
| FaxNumber: | 5188729265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 04/06/2011 | ||||||||
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| AuthorizedOfficialLastName: | KOLANCHICK | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5188729262 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 142539 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00714705 | 05 | NY | MEDICAID |