Provider Demographics
NPI:1033178066
Name:KAVANAH, MAUREEN T (MD)
Entity Type:Individual
Prefix:DR
First Name:MAUREEN
Middle Name:T
Last Name:KAVANAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:830 HARRISON AVE
Practice Address - Street 2:MOAKLEY SUITE 1200
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2905
Practice Address - Country:US
Practice Address - Phone:617-638-8655
Practice Address - Fax:617-638-8653
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA44436208600000X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110003694AMedicaid
MA110003694AMedicaid