=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538161278
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL W CAVANAUGH P.A.-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2005
-----------------------------------------------------
Last Update Date | 03/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 VINCENT ST
-----------------------------------------------------
City | STEVENS POINT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54481-1842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-344-0701
-----------------------------------------------------
Fax | 715-344-4494
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 VINCENT ST
-----------------------------------------------------
City | STEVENS POINT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54481-1842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-344-0701
-----------------------------------------------------
Fax | 715-344-4494
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 1864-023
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 1864-23
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------