Provider Demographics
NPI:1073523189
Name:JAMES L CAVANAUGH JR MD & STEPHANIE VONAMMON CAVANAUGH MD SC
Entity Type:Organization
Organization Name:JAMES L CAVANAUGH JR MD & STEPHANIE VONAMMON CAVANAUGH MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVANAUGH
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:312-829-1463
Mailing Address - Street 1:300 S ASHLAND AVE
Mailing Address - Street 2:207
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2701
Mailing Address - Country:US
Mailing Address - Phone:312-829-1463
Mailing Address - Fax:
Practice Address - Street 1:300 S ASHLAND AVE
Practice Address - Street 2:207
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2701
Practice Address - Country:US
Practice Address - Phone:312-829-1463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360431212084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21603687OtherBLUE CROSS/SHIELD
IL21603735OtherBLUE CROSS/SHIELD
IL217090Medicare PIN