Healthcare Provider Details

I. General information

NPI: 1427393149
Provider Name (Legal Business Name): ST PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MARYS AVE SUITE 3
KINGSTON NY
12401-5852
US

IV. Provider business mailing address

4 ATRIUM DR SUITE 100
ALBANY NY
12205-1441
US

V. Phone/Fax

Practice location:
  • Phone: 845-339-3663
  • Fax: 845-339-3629
Mailing address:
  • Phone: 518-435-2740
  • Fax: 518-649-4060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology 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