1356355366 NPI number — ELISA M KAVANAGH DPM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356355366 NPI number — ELISA M KAVANAGH DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KAVANAGH
Provider First Name:
ELISA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356355366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
440 MAMARONECK AVE STE 502
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARRISON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10528-2433
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-472-1000
Provider Business Mailing Address Fax Number:
914-472-1008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
440 MAMARONECK AVE STE 502
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARRISON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10528-2433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-472-1000
Provider Business Practice Location Address Fax Number:
914-472-1008
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  005920 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: 005920 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P2738692 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2404394 . This is a "UNITED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6298866 . This is a "GHI PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000082282 . This is a "GHI HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: PH7951 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1582677 . This is a "CIGNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 160452P . This is a "HIP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3C6175 . This is a "HEALTHNET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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