Provider Demographics
NPI:1659321024
Name:TERVO, KRISTINA M (DO)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:M
Last Name:TERVO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 W GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:CHITTENANGO
Mailing Address - State:NY
Mailing Address - Zip Code:13037-1528
Mailing Address - Country:US
Mailing Address - Phone:315-687-5100
Mailing Address - Fax:315-687-0252
Practice Address - Street 1:153 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:CHITTENANGO
Practice Address - State:NY
Practice Address - Zip Code:13037-1528
Practice Address - Country:US
Practice Address - Phone:315-687-5100
Practice Address - Fax:315-687-0252
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY270560207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4790962Medicaid
MI1022823OtherMHP HAN
MI4971019Medicaid
MIF43326Medicare UPIN
MI4790990Medicaid
MIOP40350007Medicare ID - Type Unspecified
MI4790980Medicaid