Provider Demographics
NPI:1427394675
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:ST. PETER'S GYNECOLOGY
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:518-649-4094
Practice Address - Street 1:31 LOWER HUDSON AVENUE
Practice Address - Street 2:ST PETER'S GYNCEOLOGY
Practice Address - City:GREEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:12183-1014
Practice Address - Country:US
Practice Address - Phone:518-272-9140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. PETER'S HEALTH PARTNERS MEDICAL ASSOCAITES, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-17
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No176B00000XOther Service ProvidersMidwifeGroup - Multi-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