Healthcare Provider Details

I. General information

NPI: 1366787020
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: 12/06/2012
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 TROY RD SPHMA RADIOLOGY DIVISION
RENSSELAER NY
12144-9521
US

IV. Provider business mailing address

PO BOX 14890
ALBANY NY
12212-4890
US

V. Phone/Fax

Practice location:
  • Phone: 518-880-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax: 518-525-6199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

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