Healthcare Provider Details

I. General information

NPI: 1659327195
Provider Name (Legal Business Name): PATRICIA MAUREEN GAVIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

IV. Provider business mailing address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-2696
  • Fax: 708-783-5096
Mailing address:
  • Phone: 708-783-2696
  • Fax: 708-783-5096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01057193A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number88544
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: