Healthcare Provider Details

I. General information

NPI: 1619909140
Provider Name (Legal Business Name): PATRICIA L KAVANAGH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HARRISON AVE YACC5
BOSTON MA
02118-4001
US

IV. Provider business mailing address

366 SHREWSBURY ST
WORCESTER MA
01604-4647
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-5946
  • Fax: 617-414-4541
Mailing address:
  • Phone: 508-595-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number229930
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: