Provider Demographics
NPI:1033465539
Name:STATE UNIVERSITY OF NEW YORK COLLEGE AT BROCKPORT
Entity Type:Organization
Organization Name:STATE UNIVERSITY OF NEW YORK COLLEGE AT BROCKPORT
Other - Org Name:SUNY BROCKPORT STUDENT HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:VERGAMINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-395-5144
Mailing Address - Street 1:350 NEW CAMPUS DR
Mailing Address - Street 2:HAZEN HALL
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-2997
Mailing Address - Country:US
Mailing Address - Phone:585-395-2414
Mailing Address - Fax:
Practice Address - Street 1:350 NEW CAMPUS DR
Practice Address - Street 2:HAZEN HALL
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-2997
Practice Address - Country:US
Practice Address - Phone:585-395-2414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health