Provider Demographics
NPI:1427393149
Name:ST PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:ST PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, PC
Other - Org Name:PRIME CARE-111 MARY'S AVE-
Other - Org Type:Other Name
Authorized Official - Title/Position:DIR FIN/ADMIN PHYS ENTERPRISE
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-525-1585
Mailing Address - Street 1:4 ATRIUM DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1441
Mailing Address - Country:US
Mailing Address - Phone:518-435-2740
Mailing Address - Fax:518-649-4060
Practice Address - Street 1:111 MARYS AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-5852
Practice Address - Country:US
Practice Address - Phone:845-339-3663
Practice Address - Fax:845-339-3629
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-06
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty