Provider Demographics
NPI:1023082351
Name:CAVANAUGH, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 SHAFFER ST
Practice Address - Street 2:
Practice Address - City:SOUTH WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17702-6727
Practice Address - Country:US
Practice Address - Phone:570-326-2447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD069473L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G82649Medicare UPIN
G82649Medicare UPIN
PAGU039777OtherMEDICARE GROUP
PA0017428360003Medicaid
NY02083732Medicaid
PA080176504OtherRR MEDICARE PIN
G82649Medicare UPIN