Healthcare Provider Details

I. General information

NPI: 1053517664
Provider Name (Legal Business Name): KEVIN E GASKIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E ADAMS ST
SYRACUSE NY
13210-2306
US

IV. Provider business mailing address

251 SALINA MEADOWS PKWY STE 100
SYRACUSE NY
13212-4516
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-4363
  • Fax: 315-464-8690
Mailing address:
  • Phone: 315-464-2096
  • Fax: 315-464-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number276967
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36227
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: