Healthcare Provider Details

I. General information

NPI: 1760727325
Provider Name (Legal Business Name): ST PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2012
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 ALBANY SHAKER RD SUITE 102
ALBANY NY
12204-1030
US

IV. Provider business mailing address

315 S MANNING BLVD
ALBANY NY
12208-1707
US

V. Phone/Fax

Practice location:
  • Phone: 518-207-2710
  • Fax: 518-207-2713
Mailing address:
  • Phone: 518-525-1585
  • Fax: 518-525-6199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL GORDON
Title or Position: DIR FIN/ADMIN PHYS ENTERPRISE
Credential:
Phone: 518-525-1585