Provider Demographics
NPI:1053332189
Name:VASCULAR SURGERY OF THE UNIVERSITY
Entity Type:Organization
Organization Name:VASCULAR SURGERY OF THE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR OF FINANCE - URMFG
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:M
Authorized Official - Last Name:HETTERICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-756-4008
Mailing Address - Street 1:601 ELMWOOD AVENUE BOX SURG
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-8410
Mailing Address - Country:US
Mailing Address - Phone:585-275-1984
Mailing Address - Fax:585-756-7750
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-758-7743
Practice Address - Fax:585-756-7750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02676933Medicaid
NYBA0561Medicare ID - Type Unspecified