Healthcare Provider Details

I. General information

NPI: 1144565714
Provider Name (Legal Business Name): ST. PETER'S HEALTH PARTNERS MEDICAL ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2012
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1444 WESTERN AVE STE B2 ST PETER'S INTERNAL AND FAMILY MEDICINE
ALBANY NY
12203-3458
US

IV. Provider business mailing address

PO BOX 14890
ALBANY NY
12212-4890
US

V. Phone/Fax

Practice location:
  • Phone: 518-458-8014
  • Fax:
Mailing address:
  • Phone:
  • Fax: 518-525-6199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: COURTNEY KNOWLES
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 518-525-5634