Basic Information
Provider Information | |||||||||
NPI: | 1760727325 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | 63 SHAKER ROAD-SUITE 102 | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 315 S MANNING BLVD | ||||||||
Address2: |   | ||||||||
City: | ALBANY | ||||||||
State: | NY | ||||||||
PostalCode: | 122081707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5185251585 | ||||||||
FaxNumber: | 5185256199 | ||||||||
Practice Location | |||||||||
Address1: | 63 ALBANY SHAKER RD | ||||||||
Address2: | SUITE 102 | ||||||||
City: | ALBANY | ||||||||
State: | NY | ||||||||
PostalCode: | 122041030 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5182072710 | ||||||||
FaxNumber: | 5182072713 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/07/2012 | ||||||||
LastUpdateDate: | 01/21/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GORDON | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIR FIN/ADMIN PHYS ENTERPRISE | ||||||||
AuthorizedOfficialTelephone: | 5185251585 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ST PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, PC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.