Provider Demographics
NPI:1619032497
Name:KAVANAGH, MICHAEL P (CPO)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:P
Last Name:KAVANAGH
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 PERRYS MILL RD
Mailing Address - Street 2:
Mailing Address - City:PINE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:31822-5112
Mailing Address - Country:US
Mailing Address - Phone:706-663-9715
Mailing Address - Fax:770-683-4872
Practice Address - Street 1:6600 VAN AALST BLVD
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-2102
Practice Address - Country:US
Practice Address - Phone:762-408-1467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA34224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA836804665AMedicaid