MEDICARE: KARA KORFONTA PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	022650-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4141955	OTHER	NY	MVP

General Provider Information

NPI Number	:	1497753230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KARA KORFONTA PT

Provider Business Mailing Address
First Line	:	1 KIRKLAND AVE
Second Line	:	SUITE 201/202
City	:	CLINTON
State	:	NY
Zip	:	13323-1426
Country	:	US
Telephone Number	:	315-853-1401
Fax Number	:	315-853-7629

Provider Business Practice Location Address
First Line	:	1 KIRKLAND AVE
Second Line	:	SUITE 201/202
City	:	CLINTON
State	:	NY
Zip	:	13323-1426
Country	:	US
Telephone Number	:	315-853-1401
Fax Number	:	315-853-7629

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	07/08/2007

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