Basic Information
| Provider Information | |||||||||
| NPI: | 1730177825 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOGAN-MOULTON | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 304 | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128010304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189261770 | ||||||||
| FaxNumber: | 5189261799 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 BROAD STREET PLZ | ||||||||
| Address2: | BROAD STREET MEDICAL GROUP | ||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189261770 | ||||||||
| FaxNumber: | 5189261799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 06/05/2012 | ||||||||
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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 | 207RN0300X | 210381 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207R00000X | 210381 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 390006064 | 01 | NY | RR MEDICARE | OTHER | 01824359 | 05 | NY | MEDICAID |