Basic Information
| Provider Information | |||||||||
| NPI: | 1366787020 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. PETER'S HEALTH PARTNERS MEDICAL ASSOCIATES, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPHPMA RADIOLOGY DIVISION | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14890 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122124890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 5185256199 | ||||||||
| Practice Location | |||||||||
| Address1: | 279 TROY RD | ||||||||
| Address2: | SPHMA RADIOLOGY DIVISION | ||||||||
| City: | RENSSELAER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121449521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188806300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2012 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | KNOWLES | ||||||||
| AuthorizedOfficialFirstName: | COURTNEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5185255634 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. PETER'S HEALTH PARTNERS MEDICAL ASSOCIATES, P.C. | ||||||||
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| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.