Provider Demographics
NPI:1134142458
Name:MCAVENEY, KEVIN M (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:MCAVENEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 BOATNER RD STE 114
Mailing Address - Street 2:
Mailing Address - City:EGLIN AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32542-1302
Mailing Address - Country:US
Mailing Address - Phone:850-883-8600
Mailing Address - Fax:
Practice Address - Street 1:307 BOATNER RD STE 114
Practice Address - Street 2:
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542
Practice Address - Country:US
Practice Address - Phone:850-883-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07820100207Q00000X
PAOS008264L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2685214000OtherAMERIHEALTH
NJ1208377OtherAETNA
NJ299169OtherAMERIGRUOP
NJ221820210OtherINDEPENDENCE BCBC
NJF97971Medicare UPIN
NJ2685214000OtherAMERIHEALTH