Healthcare Provider Details

I. General information

NPI: 1154744753
Provider Name (Legal Business Name): ST. PETERS HEALTH PARTNERS MEDICAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2014
Last Update Date: 06/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 TROY RD
RENSSELAER NY
12144-9518
US

IV. Provider business mailing address

279 TROY RD
RENSSELAER NY
12144-9518
US

V. Phone/Fax

Practice location:
  • Phone: 518-694-3053
  • Fax: 518-694-3056
Mailing address:
  • Phone: 518-694-3053
  • Fax: 518-694-3056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

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