Healthcare Provider Details

I. General information

NPI: 1154376770
Provider Name (Legal Business Name): ST. JOSEPH'S PHYSICIAN HEALTH, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 BURDETT AVE
TROY NY
12180-2466
US

IV. Provider business mailing address

425 NEW SCOTLAND AVENUE PAYER CREDENTIALING
ALBANY NY
12208
US

V. Phone/Fax

Practice location:
  • Phone: 518-271-3300
  • Fax:
Mailing address:
  • Phone: 518-525-5634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM JOSEPH KOWAL
Title or Position: PRESIDENT
Credential: MD
Phone: 518-525-5634