Healthcare Provider Details

I. General information

NPI: 1104819697
Provider Name (Legal Business Name): KENNETH J KAVANAUGH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E COUNTYLINE RD
SANDWICH IL
60548-2178
US

IV. Provider business mailing address

1 E COUNTYLINE RD
SANDWICH IL
60548-2178
US

V. Phone/Fax

Practice location:
  • Phone: 815-786-2722
  • Fax: 815-786-6840
Mailing address:
  • Phone: 815-786-2722
  • Fax: 815-786-6840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036077591
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: