Provider Demographics
NPI:1679660336
Name:SUNY POTSDAM STUDENT HEALTH SERVICES
Entity Type:Organization
Organization Name:SUNY POTSDAM STUDENT HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF STUDENT HEALTH SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:BARTLETT
Authorized Official - Last Name:DOELGER
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:315-267-2377
Mailing Address - Street 1:44 PIERREPONT AVE
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-2200
Mailing Address - Country:US
Mailing Address - Phone:315-267-2377
Mailing Address - Fax:
Practice Address - Street 1:44 PIERREPONT AVE
Practice Address - Street 2:STUDENT HEALTH SERVICES
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-2200
Practice Address - Country:US
Practice Address - Phone:315-267-2377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QS1000X261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY301604OtherLICENSE NUMBER
NY106764OtherLICENSE NUMBER
NY301038OtherLICENSE NUMBER
NY334042OtherLICENSE NUMBER