MEDICARE: JOHN M. CAVENAGH PA

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	363A00000X	Physician Assistant	OA000378L	PA
2	363A00000X	Physician Assistant	MA000252L	PA

General Provider Information

NPI Number	:	1649271313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN M. CAVENAGH PA

Provider Business Mailing Address
First Line	:	4190 CITY LINE AVE
Second Line	:	SUITE 315
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-1626
Country	:	US
Telephone Number	:	215-871-6380
Fax Number	:	215-871-6381

Provider Business Practice Location Address
First Line	:	4190 CITY LINE AVE
Second Line	:	SUITE 315
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-1626
Country	:	US
Telephone Number	:	215-871-6380
Fax Number	:	215-871-6381

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

Provider Enumeration Date	:	08/03/2005
Last Update Date	:	04/08/2009

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Directions to “ JOHN M. CAVENAGH PA” Practice Location

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