1679660336 NPI number — SUNY POTSDAM STUDENT HEALTH SERVICES

Table of content: (NPI 1679660336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679660336 NPI number — SUNY POTSDAM STUDENT HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNY POTSDAM STUDENT HEALTH SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679660336
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44 PIERREPONT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POTSDAM
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13676-2200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-267-2377
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44 PIERREPONT AVE
Provider Second Line Business Practice Location Address:
STUDENT HEALTH SERVICES
Provider Business Practice Location Address City Name:
POTSDAM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13676-2200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-267-2377
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOELGER
Authorized Official First Name:
MARILYN
Authorized Official Middle Name:
BARTLETT
Authorized Official Title or Position:
DIRECTOR OF STUDENT HEALTH SERVICES
Authorized Official Telephone Number:
315-267-2377

Provider Taxonomy Codes

  • Taxonomy code: 261QS1000X , with the licence number:  261QS1000X , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 301604 . This is a "LICENSE NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 106764 . This is a "LICENSE NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 301038 . This is a "LICENSE NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 334042 . This is a "LICENSE NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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