Provider Demographics
NPI:1902845621
Name:TERRENCE, KATHLEEN M (MD)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:M
Last Name:TERRENCE
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 1:50 LEROY STREET
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1979
Mailing Address - Country:US
Mailing Address - Phone:315-265-3300
Mailing Address - Fax:
Practice Address - Street 1:80 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617
Practice Address - Country:US
Practice Address - Phone:315-261-7180
Practice Address - Fax:315-261-6330
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216697208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02107940Medicaid
NY366605OtherMVP INS PROVIDER NUMBER