Healthcare Provider Details

I. General information

NPI: 1245628361
Provider Name (Legal Business Name): ST. PETERS HEALTH PARTNERS MEDICAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2014
Last Update Date: 12/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 S MANNING BLVD SUITE 304
ALBANY NY
12208-1742
US

IV. Provider business mailing address

319 S MANNING BLVD SUITE 304
ALBANY NY
12208-1742
US

V. Phone/Fax

Practice location:
  • Phone: 518-525-5206
  • Fax: 518-525-5209
Mailing address:
  • Phone: 518-525-5206
  • Fax: 518-525-5209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL GORDON
Title or Position: CFO PHYSICIAN ENTERPRISE
Credential:
Phone: 518-525-1585