Provider Demographics
NPI:1023389533
Name:KOINONIA PRIMARY CARE INC
Entity Type:Organization
Organization Name:KOINONIA PRIMARY CARE INC
Other - Org Name:KOINONIA PRIMARY MEDICAL CARE PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:PAEGLOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-689-0282
Mailing Address - Street 1:553 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206-2738
Mailing Address - Country:US
Mailing Address - Phone:518-689-0282
Mailing Address - Fax:518-689-0283
Practice Address - Street 1:553 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-2738
Practice Address - Country:US
Practice Address - Phone:518-689-0282
Practice Address - Fax:518-689-0283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-16
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center