Healthcare Provider Details

I. General information

NPI: 1821535592
Provider Name (Legal Business Name): ST. PETER'S HEALTH PARTNERS MEDICAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 TROY SCHENECTADY RD STE 304 ST. PETER'S OB/GYN AT LATHAM
LATHAM NY
12110-2490
US

IV. Provider business mailing address

PO BOX 14890 ST. PETER'S PAYER CREDENTIALING
ALBANY NY
12212-4890
US

V. Phone/Fax

Practice location:
  • Phone: 518-786-6270
  • Fax: 518-786-6276
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JANICE MACKE
Title or Position: CFO
Credential:
Phone: 518-525-6931