Provider Demographics
NPI:1629088745
Name:CAVANAUGH, JAMES L JR (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:L
Last Name:CAVANAUGH
Suffix:JR
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 1:300 S ASHLAND AVE
Mailing Address - Street 2:207
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2701
Mailing Address - Country:US
Mailing Address - Phone:312-829-1463
Mailing Address - Fax:
Practice Address - Street 1:300 S ASHLAND AVE
Practice Address - Street 2:207
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2701
Practice Address - Country:US
Practice Address - Phone:312-829-1463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360431212084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036043121Medicaid
IL21603687OtherBLUE CROSS/SHIELD
ILK53322Medicare PIN