Provider Demographics
NPI:1164449138
Name:CAVANAUGH, JEAN ANN (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:ANN
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 1:2650 RIDGE AVE
Mailing Address - Street 2:EVANSTON HOSPITAL
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-1206
Mailing Address - Fax:847-570-1248
Practice Address - Street 1:2650 RIDGE AVE
Practice Address - Street 2:DEPARTMENT OF PHYS MED SUITE 2204
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1718
Practice Address - Country:US
Practice Address - Phone:847-570-2066
Practice Address - Fax:847-570-2901
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1620385OtherBCBS PPO
D13086Medicare UPIN
ILL76175Medicare PIN
IL1620385OtherBCBS PPO