Healthcare Provider Details

I. General information

NPI: 1427045723
Provider Name (Legal Business Name): STEPHEN FW CAVANAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2005
Last Update Date: 11/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 POPLAR LEVEL RD STE.301
LOUISVILLE KY
40217-1395
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 502-636-0406
  • Fax:
Mailing address:
  • Phone: 502-272-5063
  • Fax: 502-272-5339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number23372
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: