Provider Demographics
NPI:1558441808
Name:GAVAGAN, THOMAS (MPH)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:GAVAGAN
Suffix:
Gender:M
Credentials:MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2231 E 95TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-4804
Mailing Address - Country:US
Mailing Address - Phone:773-768-7700
Mailing Address - Fax:773-768-7768
Practice Address - Street 1:2231 E 95TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-4804
Practice Address - Country:US
Practice Address - Phone:773-768-7700
Practice Address - Fax:773-768-7768
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-067636207Q00000X
TXL5341207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8078M9Medicaid
C47641Medicare UPIN