Healthcare Provider Details

I. General information

NPI: 1558514380
Provider Name (Legal Business Name): MARK L KAVANAGH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2008
Last Update Date: 01/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 BEAVERBROOK RD SUITE 201
LINCOLN PARK NJ
07035-1748
US

IV. Provider business mailing address

61 BEAVERBROOK RD SUITE 201
LINCOLN PARK NJ
07035-1748
US

V. Phone/Fax

Practice location:
  • Phone: 973-686-9292
  • Fax: 973-686-9294
Mailing address:
  • Phone: 973-686-9292
  • Fax: 973-686-9294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number0101245447
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number25MA08991900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: