Provider Demographics
NPI:1174600555
Name:KAVANAGH, PHILIP RICHARD (DO)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:RICHARD
Last Name:KAVANAGH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 DOUGLAS RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1781
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:615 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1033
Practice Address - Country:US
Practice Address - Phone:574-647-7459
Practice Address - Fax:574-647-3658
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002062A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200252410Medicaid
MI4392339Medicaid
INH20027Medicare UPIN
IN941030QQMedicare ID - Type UnspecifiedMEMORIAL HOSP - RENDERING