Provider Demographics
NPI:1356686331
Name:ST. PETER'S HEALTH PARTNERS MEDICAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:ST. PETER'S HEALTH PARTNERS MEDICAL ASSOCIATES, P.C.
Other - Org Name:BRAVERMAN-PANZA INTERNAL MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOWLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-525-5634
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1375 WASHINGTON AVE STE 202
Practice Address - Street 2:ST. PETER'S INTERNAL MEDICINE
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-1056
Practice Address - Country:US
Practice Address - Phone:518-482-0007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. PETER'S HEALTH PARTNERS MEDICAL ASSOCIATES, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-03
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03539695Medicaid