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General NPI Number Information
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NPI Number | 1124137096
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Entity Type | Organization
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Legal Business Name | US DEPARTMENT OF VETERANS AFFAIRS
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Dates
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Enumeration Date | 08/30/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 800 IRVING AVE
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City | SYRACUSE
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State | NY
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Zip | 13210-2716
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Country | US
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Telephone | 315-425-4400
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Fax |
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Provider Business Mailing Address
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Address Line | 8036 YAGER RD
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City | BLOSSVALE
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State | NY
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Zip | 13308-2926
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Country | US
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Telephone | 315-334-7100
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Fax |
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Authorized Official
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Title or Position | SOCIAL WORKER
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Name | MR. EDWIN DAVID GWYTHER
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Credential | LMSW
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Telephone | 315-334-7100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 064482
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License Number State | NY
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