Basic Information
| Provider Information | |||||||||
| NPI: | 1164635652 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OZOG | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | AMY | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 231 WALTON STREET | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132061230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154780380 | ||||||||
| FaxNumber: | 3154780388 | ||||||||
| Practice Location | |||||||||
| Address1: | 419 N. MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | HERKIMER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157170278 | ||||||||
| FaxNumber: | 3157170280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 10/21/2010 | ||||||||
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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 | 225100000X | 028440-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | AA0172 | 01 | NY | MCR GRP | OTHER | 1710923222 | 01 | NY | NPI GRP | OTHER | AA0171 | 01 | NY | MCR GROUP | OTHER | 02052091 | 05 | NY | MEDICAID |