MEDICARE: JOHN W KAVANAUGH JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	4301405215	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	238601	OTHER	MI	MEDICARE RURAL HEALTH CLINIC NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609858844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN W KAVANAUGH JR. MD

Provider Business Mailing Address
First Line	:	451 HEALTH PKWY
Second Line	:	SUITE E
City	:	PAW PAW
State	:	MI
Zip	:	49079-8242
Country	:	US
Telephone Number	:	269-655-3090
Fax Number	:	269-655-0763

Provider Business Practice Location Address
First Line	:	451 HEALTH PKWY
Second Line	:	SUITE E
City	:	PAW PAW
State	:	MI
Zip	:	49079-8242
Country	:	US
Telephone Number	:	269-655-3090
Fax Number	:	269-655-0763

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	10/16/2014

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Directions to “ JOHN W KAVANAUGH JR. MD” Practice Location

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