Healthcare Provider Details

I. General information

NPI: 1508247487
Provider Name (Legal Business Name): ST. PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 S CENTRAL AVE
MECHANICVILLE NY
12118-3522
US

IV. Provider business mailing address

4 PALISADES DR SUITE 200
ALBANY NY
12205-1449
US

V. Phone/Fax

Practice location:
  • Phone: 518-664-6125
  • Fax:
Mailing address:
  • Phone: 518-435-2745
  • Fax: 518-649-4060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

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