=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669442620
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL PHILIP GAVIN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2006
-----------------------------------------------------
Last Update Date | 03/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 141 HOSPITAL DR
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42078-8043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-988-3298
-----------------------------------------------------
Fax | 270-988-4642
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 141 HOSPITAL DR PO BOX 347
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42078-8043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-988-3298
-----------------------------------------------------
Fax | 270-988-4642
-----------------------------------------------------
=====================================================
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 | 21359
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 21359
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------