Healthcare Provider Details

I. General information

NPI: 1851705453
Provider Name (Legal Business Name): RYAN LEE BURYTA D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 PORTLAND AVE
ROCHESTER NY
14621
US

IV. Provider business mailing address

100 KINGS HIGHWAY SOUTH PROVIDER ENROLLMENT
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-3846
  • Fax: 585-922-2951
Mailing address:
  • Phone: 585-922-1304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101021082
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number294700
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: