Basic Information
| Provider Information | |||||||||
| NPI: | 1528151461 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANCZYK | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | SAMFORT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 FOX CARE DRIVE | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | ONEONTA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6074323711 | ||||||||
| FaxNumber: | 6074326402 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 FOX CARE DRIVE | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | ONEONTA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6074323711 | ||||||||
| FaxNumber: | 6074326402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 04/19/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 1620101 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00899665 | 05 | NY | MEDICAID |