Provider Demographics
NPI:1730177825
Name:HOGAN-MOULTON, AMY ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:HOGAN-MOULTON
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 304
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-0304
Mailing Address - Country:US
Mailing Address - Phone:518-926-1770
Mailing Address - Fax:518-926-1799
Practice Address - Street 1:2 BROAD STREET PLZ
Practice Address - Street 2:BROAD STREET MEDICAL GROUP
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4363
Practice Address - Country:US
Practice Address - Phone:518-926-1770
Practice Address - Fax:518-926-1799
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210381207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY390006064OtherRR MEDICARE
NY01824359Medicaid
NY390006064OtherRR MEDICARE
NY01824359Medicaid