Provider Demographics
NPI:1225122054
Name:KOINONIA HEALTHCARE
Entity Type:Organization
Organization Name:KOINONIA HEALTHCARE
Other - Org Name:KOINONIA PRIMARY CARE AND PSYCHIATRIC SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
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 AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206
Mailing Address - Country:US
Mailing Address - Phone:518-689-0282
Mailing Address - Fax:
Practice Address - Street 1:553 CLINTON AVENUE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206
Practice Address - Country:US
Practice Address - Phone:518-689-0282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60/201542261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01753680Medicaid
NYG9202OtherCDPHP GROUP
NYG9202OtherCDPHP GROUP