Basic Information
| Provider Information | |||||||||
| NPI: | 1033170840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KANTOR | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 214 KING ST | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153933600 | ||||||||
| FaxNumber: | 3153935802 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 KING STREET | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153933600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 05/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 5101007040 | MI | N | Other Service Providers | Specialist | 174400000X | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 3405630875 | 01 | MI | BLUE CROSS BLUE SHEILD | OTHER | 03266786 | 05 | NY | MEDICAID | 382032989 | 01 | MI | COMMERCIAL | OTHER | KK007040 | 01 | MI | BLUE CROSS BLUE SHEILD | OTHER | P00472866 | 01 | MI | MEDICARE RAIL ROAD | OTHER | 3405630875 | 01 | MI | BLUE CARE NETWORK | OTHER |