Healthcare Provider Details

I. General information

NPI: 1629294145
Provider Name (Legal Business Name): MICHAEL JAMES MCAVOY D. O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 N MEADE ST
APPLETON WI
54911-3762
US

IV. Provider business mailing address

1520 N MEADE ST
APPLETON WI
54911-3762
US

V. Phone/Fax

Practice location:
  • Phone: 920-734-7181
  • Fax: 920-734-0621
Mailing address:
  • Phone: 920-734-7181
  • Fax: 920-734-0621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number5101015981
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: