Basic Information
| Provider Information | |||||||||
| NPI: | 1831434588 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, PC | ||||||||
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| OtherOrganizationName: | PRIME CARE-17 GLENN POND ROAD | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 S MANNING BLVD | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122081707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185251585 | ||||||||
| FaxNumber: | 5185256199 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 GLEN POND DR | ||||||||
| Address2: | |||||||||
| City: | RED HOOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125711840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457586046 | ||||||||
| FaxNumber: | 8457586051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2012 | ||||||||
| LastUpdateDate: | 01/21/2014 | ||||||||
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| AuthorizedOfficialLastName: | GORDON | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIR FIN/ADMIN PHYS ENTERPRISE | ||||||||
| AuthorizedOfficialTelephone: | 5185251585 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, PC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.