Healthcare Provider Details

I. General information

NPI: 1073523189
Provider Name (Legal Business Name): JAMES L CAVANAUGH JR MD & STEPHANIE VONAMMON CAVANAUGH MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S ASHLAND AVE 207
CHICAGO IL
60607-2701
US

IV. Provider business mailing address

300 S ASHLAND AVE 207
CHICAGO IL
60607-2701
US

V. Phone/Fax

Practice location:
  • Phone: 312-829-1463
  • Fax:
Mailing address:
  • Phone: 312-829-1463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number036043121
License Number StateIL

VIII. Authorized Official

Name: JAMES CAVANAUGH JR.
Title or Position: OWNER
Credential: MD
Phone: 312-829-1463