MEDICARE: ST. PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1508247487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, PC

Provider Business Mailing Address
First Line	:	4 PALISADES DR
Second Line	:	SUITE 200
City	:	ALBANY
State	:	NY
Zip	:	12205-1449
Country	:	US
Telephone Number	:	518-435-2745
Fax Number	:	518-649-4060

Provider Business Practice Location Address
First Line	:	202 S CENTRAL AVE
Second Line	:
City	:	MECHANICVILLE
State	:	NY
Zip	:	12118-3522
Country	:	US
Telephone Number	:	518-664-6125
Fax Number	:

Authorized Official
Title or Position	:	CFO PHYSICIAN ENTERPRISES
Name	:	PAUL GORDON
Credential	:
Telephone Number	:	518-525-1585

Provider Enumeration Date	:	06/16/2015
Last Update Date	:	06/16/2015

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