Provider Demographics
NPI:1417949850
Name:DEPAUL
Entity Type:Organization
Organization Name:DEPAUL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WHALEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-426-8000
Mailing Address - Street 1:1931 BUFFALO RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-1535
Mailing Address - Country:US
Mailing Address - Phone:585-426-8000
Mailing Address - Fax:585-426-8082
Practice Address - Street 1:774 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14611-2331
Practice Address - Country:US
Practice Address - Phone:585-464-8870
Practice Address - Fax:585-464-8077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00689721Medicaid