Provider Demographics
NPI:1154484111
Name:KAVANAUGH, PETER SHAUN (DC)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:SHAUN
Last Name:KAVANAUGH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:P
Other - Middle Name:SHAUN
Other - Last Name:KAVANAUGH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:3301 RYAN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19136
Mailing Address - Country:US
Mailing Address - Phone:215-332-8686
Mailing Address - Fax:215-332-8691
Practice Address - Street 1:3301 RYAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19136-4301
Practice Address - Country:US
Practice Address - Phone:215-332-8686
Practice Address - Fax:215-332-8691
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1897111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0061018000OtherKEYSTONE
PA087374Medicaid
PA2142140000OtherPERSONAL CHOICE
PA087374Medicaid