Provider Demographics
NPI:1497701106
Name:ST. PETER'S HOSPITAL OF THE CITY OF ALBANY
Entity Type:Organization
Organization Name:ST. PETER'S HOSPITAL OF THE CITY OF ALBANY
Other - Org Name:ST. PETER'S ADDICTION RECOVERY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING & ENROLLMENT 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 1:315 S MANNING BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1707
Practice Address - Country:US
Practice Address - Phone:518-525-1550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. PETER'S HOSPITAL OF THE CITY OF ALBANY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-25
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207QA0401X, 207R00000X, 2084P0800X, 276400000X, 363A00000X, 363L00000X, 363LF0000X, 363LP0808X
NY0101114H282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care HospitalGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No276400000XHospital UnitsRehabilitation, Substance Use Disorder UnitGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000022OtherEMPIRE BC
000400022000OtherBS NORTHEAST NY
10005852OtherCDPHO
NY00318823Medicaid
000400022000OtherBS NORTHEAST NY