=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871483172
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. PETER'S HEALTH PARTNERS MEDICAL ASSOCIATES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2025
-----------------------------------------------------
Last Update Date | 07/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 319 S MANNING BLVD STE 301
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12208-1743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-458-1390
-----------------------------------------------------
Fax | 518-694-8872
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 14890
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12212-4890
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | GARY TERK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 518-525-5634
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VX0201X
-----------------------------------------------------
Taxonomy Name | Gynecologic Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2086X0206X
-----------------------------------------------------
Taxonomy Name | Surgical Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------