Provider Demographics
NPI:1174562482
Name:KAVANAGH, KRISTEN ELIZABETH (DO)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ELIZABETH
Last Name:KAVANAGH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:ELIZABETH
Other - Last Name:WEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:51221 SCHOENHERR RD STE 201
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-2718
Mailing Address - Country:US
Mailing Address - Phone:586-323-4450
Mailing Address - Fax:586-323-4448
Practice Address - Street 1:51221 SCHOENHERR RD STE 201
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48315-2718
Practice Address - Country:US
Practice Address - Phone:586-323-4450
Practice Address - Fax:586-323-4448
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015629207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4901604Medicaid
I53029Medicare UPIN