Provider Demographics
NPI:1760727325
Name:ST PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:ST PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, PC
Other - Org Name:63 SHAKER ROAD-SUITE 102
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 1:315 S MANNING BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-1707
Mailing Address - Country:US
Mailing Address - Phone:518-525-1585
Mailing Address - Fax:518-525-6199
Practice Address - Street 1:63 ALBANY SHAKER RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12204-1030
Practice Address - Country:US
Practice Address - Phone:518-207-2710
Practice Address - Fax:518-207-2713
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-07
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty