Healthcare Provider Details

I. General information

NPI: 1194782938
Provider Name (Legal Business Name): UPSTATE VASCULAR STUDY LAB, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 RIDGEWAY AVENUE SUITE # 260
ROCHESTER NY
14626
US

IV. Provider business mailing address

2655 RIDGEWAY AVENUE SUITE # 260
ROCHESTER NY
14626
US

V. Phone/Fax

Practice location:
  • Phone: 585-720-0818
  • Fax: 585-720-5427
Mailing address:
  • Phone: 585-720-0818
  • Fax: 585-720-5427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number124377
License Number StateNY

VIII. Authorized Official

Name: MRS. TIFFANY A. BURGEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 585-720-0818