Provider Demographics
NPI:1073523015
Name:CAVANAUGH, STEPHANIE V (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:V
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:IL
Mailing Address - Zip Code:60093-2148
Mailing Address - Country:US
Mailing Address - Phone:312-829-1463
Mailing Address - Fax:
Practice Address - Street 1:1210 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:IL
Practice Address - Zip Code:60093-2148
Practice Address - Country:US
Practice Address - Phone:312-829-1463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360419632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036041963Medicaid
ILF400289272Medicare PIN
IL036041963Medicaid
IL260016681OtherRAIL ROAD MEDICARE
ILK53323Medicare PIN