MEDICARE: DR. PETER SHAUN KAVANAUGH DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	1897	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0061018000	OTHER	PA	KEYSTONE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	2142140000	OTHER	PA	PERSONAL CHOICE

General Provider Information

NPI Number	:	1154484111
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER SHAUN KAVANAUGH DC

Provider Business Mailing Address
First Line	:	3301 RYAN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19136
Country	:	US
Telephone Number	:	215-332-8686
Fax Number	:	215-332-8691

Provider Business Practice Location Address
First Line	:	3301 RYAN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19136-4301
Country	:	US
Telephone Number	:	215-332-8686
Fax Number	:	215-332-8691

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	02/07/2012

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