Provider Demographics
NPI:1659327195
Name:GAVIN, PATRICIA MAUREEN (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MAUREEN
Last Name:GAVIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3249 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3429
Mailing Address - Country:US
Mailing Address - Phone:708-783-2696
Mailing Address - Fax:708-783-5096
Practice Address - Street 1:3249 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3429
Practice Address - Country:US
Practice Address - Phone:708-783-2696
Practice Address - Fax:708-783-5096
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057193A2085R0202X
OH885442085R0202X
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065903 1Medicaid
ILP00057215OtherRR MEDICARE
ILP00057215OtherRR MEDICARE
F76968Medicare UPIN