Provider Demographics
NPI:1669442620
Name:GAVIN, MICHAEL PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PHILIP
Last Name:GAVIN
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 1:141 HOSPITAL DR
Mailing Address - Street 2:PO BOX 347
Mailing Address - City:SALEM
Mailing Address - State:KY
Mailing Address - Zip Code:42078-8043
Mailing Address - Country:US
Mailing Address - Phone:270-988-3298
Mailing Address - Fax:270-988-4642
Practice Address - Street 1:141 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:KY
Practice Address - Zip Code:42078-8043
Practice Address - Country:US
Practice Address - Phone:270-988-3298
Practice Address - Fax:270-988-4642
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21359208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64213598Medicaid
KY020044988Medicare PIN
KY0627402Medicare PIN
KY0627301Medicare PIN
KY64213598Medicaid
KYC74353Medicare UPIN
KY0627202Medicare PIN