Basic Information
| Provider Information | |||||||||
| NPI: | 1205223294 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, P.C. | ||||||||
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| OtherOrganizationName: | SPHPMA RADIOLOGY DIVISION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14890 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122124890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185255634 | ||||||||
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| Practice Location | |||||||||
| Address1: | 147 HOOSICK STREET | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121802353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182685370 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2015 | ||||||||
| LastUpdateDate: | 02/08/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KNOWLES | ||||||||
| AuthorizedOfficialFirstName: | COURTNEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5185255634 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, P.C. | ||||||||
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| NPICertificationDate: | 02/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 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 | 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.