Provider Demographics
NPI:1114361250
Name:STEPHEN F. AUSTIN STATE UNIVERSITY
Entity Type:Organization
Organization Name:STEPHEN F. AUSTIN STATE UNIVERSITY
Other - Org Name:SFASU STUDENT HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BAKER
Authorized Official - Middle Name:
Authorized Official - Last Name:PATILLO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:936-468-4580
Mailing Address - Street 1:2106 RAQUET ST
Mailing Address - Street 2:PO BOX 13058 SFA STATION
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75962-0001
Mailing Address - Country:US
Mailing Address - Phone:936-468-4006
Mailing Address - Fax:
Practice Address - Street 1:2106 RAQUET ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75962-0001
Practice Address - Country:US
Practice Address - Phone:936-468-4006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-19
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health