Provider Demographics
NPI:1497830145
Name:CAVANAUGH, KEITH (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:CAVANAUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 CHICAGO AVE S
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4387
Mailing Address - Country:US
Mailing Address - Phone:612-813-3300
Mailing Address - Fax:612-813-3349
Practice Address - Street 1:2530 CHICAGO AVE S
Practice Address - Street 2:SUITE 400
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4387
Practice Address - Country:US
Practice Address - Phone:612-813-3300
Practice Address - Fax:612-813-3349
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO401542080P0214X
MN415902080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO38376733Medicaid
COC537118Medicare PIN
COH96614Medicare UPIN