Provider Demographics
NPI:1699705749
Name:KANYUSIK, MARJORIE (MD)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:KANYUSIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:GAYLORD HOSPITAL
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492
Mailing Address - Country:US
Mailing Address - Phone:203-284-2800
Mailing Address - Fax:203-679-3598
Practice Address - Street 1:GAYLORD HOSPITAL
Practice Address - Street 2:GAYLORD FARMS ROAD
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492
Practice Address - Country:US
Practice Address - Phone:203-284-2800
Practice Address - Fax:203-679-3598
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039926207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTF85823Medicare UPIN