Provider Demographics
NPI:1477566883
Name:CAVANAUGH, MICHAEL FRANCIS (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:FRANCIS
Last Name:CAVANAUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 MEADOWVIEW CT
Mailing Address - Street 2:
Mailing Address - City:MAPLE GLEN
Mailing Address - State:PA
Mailing Address - Zip Code:19002-2330
Mailing Address - Country:US
Mailing Address - Phone:215-643-3423
Mailing Address - Fax:
Practice Address - Street 1:1401 BETHLEHEM PIKE
Practice Address - Street 2:
Practice Address - City:FLOURTOWN
Practice Address - State:PA
Practice Address - Zip Code:19031-1904
Practice Address - Country:US
Practice Address - Phone:215-233-1001
Practice Address - Fax:215-233-9749
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031574E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011252240002Medicaid
PAC33699Medicare UPIN
PACA416093JW9Medicare ID - Type Unspecified