Basic Information
| Provider Information | |||||||||
| NPI: | 1265426423 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRYAN S EVANCZYK MD INC PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WOMENS HEALTH @ FOX CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 FOX CARE DR | ||||||||
| Address2: | STE 303 | ||||||||
| City: | ONEONTA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138202086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6074323711 | ||||||||
| FaxNumber: | 6074326402 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 FOX CARE DR | ||||||||
| Address2: | STE 303 | ||||||||
| City: | ONEONTA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138202086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6074323711 | ||||||||
| FaxNumber: | 6074326402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | EVANCZYK | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6074323711 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 1620101 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00899665 | 05 | NY | MEDICAID |