MEDICARE: SAMUEL MUDGE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	116171	NY

General Provider Information

NPI Number	:	1730056417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL MUDGE

Provider Business Mailing Address
First Line	:	8380 MORGAN RD
Second Line	:
City	:	CLAY
State	:	NY
Zip	:	13041-9614
Country	:	US
Telephone Number	:	315-507-1668
Fax Number	:

Provider Business Practice Location Address
First Line	:	723 JAMES ST
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13203-2001
Country	:	US
Telephone Number	:	315-425-0818
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2025
Last Update Date	:	10/20/2025

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Directions to “ SAMUEL MUDGE ” Practice Location

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