Provider Demographics
NPI:1104257252
Name:ST. PETERS HEALTH PARTNERS MEDICAL ASSOCIATES PC
Entity type:Organization
Organization Name:ST. PETERS HEALTH PARTNERS MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
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 1:10 GAGNON DR
Mailing Address - Street 2:
Mailing Address - City:STONE RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12484-5120
Mailing Address - Country:US
Mailing Address - Phone:548-687-7455
Mailing Address - Fax:
Practice Address - Street 1:10 GAGNON DR
Practice Address - Street 2:
Practice Address - City:STONE RIDGE
Practice Address - State:NY
Practice Address - Zip Code:12484-5120
Practice Address - Country:US
Practice Address - Phone:548-687-7455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. PETERS HEALTH PARTNERS MEDICAL ASSOCIATES, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-27
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty