Provider Demographics
NPI:1609877422
Name:CANAVAN, THOMAS E (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:CANAVAN
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 1:319 S MANNING BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-1742
Mailing Address - Country:US
Mailing Address - Phone:518-525-2542
Mailing Address - Fax:518-525-2522
Practice Address - Street 1:319 S MANNING BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1742
Practice Address - Country:US
Practice Address - Phone:518-525-2542
Practice Address - Fax:518-525-2522
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1530051208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY780000701OtherRAILROAD MEDICARE
NY00935924Medicaid
NY33723IMedicare ID - Type Unspecified
B80871Medicare UPIN