Provider Demographics
NPI:1992000640
Name:FORDAM UNIVERSITY
Entity Type:Organization
Organization Name:FORDAM UNIVERSITY
Other - Org Name:STUDENT HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:D.O.
Authorized Official - Prefix:
Authorized Official - First Name:KULRAVEE
Authorized Official - Middle Name:
Authorized Official - Last Name:KEEGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:718-817-4160
Mailing Address - Street 1:441 E FORDHAM RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-5149
Mailing Address - Country:US
Mailing Address - Phone:718-817-4160
Mailing Address - Fax:718-817-3218
Practice Address - Street 1:441 E FORDHAM RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5149
Practice Address - Country:US
Practice Address - Phone:718-817-4160
Practice Address - Fax:718-817-3218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF336467261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health