=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720312754
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY CHOICE OF NEW YORK MEDICAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2009
-----------------------------------------------------
Last Update Date | 06/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3332 WALDEN AVE SUITE 110
-----------------------------------------------------
City | DEPEW
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-668-7051
-----------------------------------------------------
Fax | 716-668-7069
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3332 WALDEN AVE SUITE 110
-----------------------------------------------------
City | DEPEW
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-668-7051
-----------------------------------------------------
Fax | 716-668-7069
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF MEDICAL OFFICER
-----------------------------------------------------
Name | DR. STEPHEN EVANS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 716-668-7051
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------