Healthcare Provider Details

I. General information

NPI: 1306973805
Provider Name (Legal Business Name): MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 SHIRLWOOD DR
SCHENECTADY NY
12306-3417
US

IV. Provider business mailing address

207 SHIRLWOOD DR
SCHENECTADY NY
12306-3417
US

V. Phone/Fax

Practice location:
  • Phone: 518-355-9281
  • Fax:
Mailing address:
  • Phone: 518-355-9281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number003438
License Number StateNY

VIII. Authorized Official

Name: MRS. COLLEEN KNAUPP
Title or Position: PHYSICIAN ASSISTANT
Credential: RPA-C
Phone: 518-471-3221