Healthcare Provider Details

I. General information

NPI: 1184648594
Provider Name (Legal Business Name): DEPARTMENT OF VETERAN AFFAIRS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 VAN BUREN RD SUITE 6
CARIBOU ME
04736-3567
US

IV. Provider business mailing address

163 VAN BUREN RD SUITE 6
CARIBOU ME
04736-3567
US

V. Phone/Fax

Practice location:
  • Phone: 207-485-1711
  • Fax: 207-493-3877
Mailing address:
  • Phone: 207-485-1711
  • Fax: 207-493-3877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number6801086877
License Number StateMI

VIII. Authorized Official

Name: JOHN P. MCEWAN
Title or Position: GEC CARE LINE MANAGER
Credential: CSW
Phone: 207-623-8411