Healthcare Provider Details

I. General information

NPI: 1669455838
Provider Name (Legal Business Name): BRIAN Y CHANGLAI MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 08/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 BRIARWOOD LN
MANLIUS NY
13104-1307
US

IV. Provider business mailing address

4921 BRIARWOOD LN
MANLIUS NY
13104-1307
US

V. Phone/Fax

Practice location:
  • Phone: 315-637-5986
  • Fax:
Mailing address:
  • Phone: 315-637-5986
  • Fax: 315-492-5855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number147291
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number147291
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number147291
License Number StateNY

VIII. Authorized Official

Name: BRIAN YISHING CHANGLAI
Title or Position: PRESIDENT
Credential: MD
Phone: 315-492-5769