Active NPI
Kenneth J Kavanaugh, DO
- Family Medicine Physician
- Sandwich, IL
National Provider Identifier
1104819697
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 036077591
- Practice address
- 1 E Countyline Rd
Sandwich, IL 60548-2178 - Phone
- (815) 786-2722
- Fax
- (815) 786-6840
- NPI assigned
- Aug 30, 2005
- Last updated
- Mar 2, 2021
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 036077591 | IL | Primary |
Addresses
Primary practice location
1 E Countyline Rd
Sandwich, IL 60548-2178
Mailing address
1 E Countyline Rd
Sandwich, IL 60548-2178
Phone (815) 786-2722
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 036077591 | Medicaid | IL | |
| 1921614 | Other | IL | BC/BS |
Electronic endpoints 1
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Direct Messaging Address | kkavanaugh14749@direct.edward.org | Direct |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Osteopathy
Interoperability endpoints
- kkavanaugh14749@direct.edward.org
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1125360000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1614643200000",
"number": "1104819697",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1 E COUNTYLINE RD",
"city": "SANDWICH",
"state": "IL",
"postal_code": "605482178",
"telephone_number": "815-786-2722",
"fax_number": "815-786-6840"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1 E COUNTYLINE RD",
"city": "SANDWICH",
"state": "IL",
"postal_code": "605482178",
"telephone_number": "815-786-2722",
"fax_number": "815-786-6840"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KAVANAUGH",
"first_name": "KENNETH",
"middle_name": "J",
"name_prefix": "Dr.",
"credential": "DO",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-08-30",
"last_updated": "2021-03-02",
"certification_date": "2021-03-02",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "IL",
"license": "036077591",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "036077591",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BC/BS",
"identifier": "1921614",
"state": "IL"
}
],
"endpoints": [
{
"endpointType": "DIRECT",
"endpointTypeDescription": "Direct Messaging Address",
"endpoint": "kkavanaugh14749@direct.edward.org",
"affiliation": "N",
"use": "DIRECT",
"useDescription": "Direct",
"contentType": "OTHER",
"contentTypeDescription": "Other",
"contentOtherDescription": "other",
"address_1": "1 E Countyline Rd",
"city": "Sandwich",
"state": "IL",
"country_code": "US",
"postal_code": "605482178",
"country_name": "United States",
"address_type": "DOM"
}
],
"other_names": []
}Other providers in Sandwich, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 2, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.