Basic Information
| Provider Information | |||||||||
| NPI: | 1336428812 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAVENAUGH | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4201 ST. ANTOINE UHC 5D | ||||||||
| Address2: | UNIVERSITY PEDIATRICIANS | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139665051 | ||||||||
| FaxNumber: | 3139660665 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 BEAUBIEN ER DEPT | ||||||||
| Address2: | CHILDREN'S HOSPITAL OF MI | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137455260 | ||||||||
| FaxNumber: | 3139937166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2011 | ||||||||
| LastUpdateDate: | 08/07/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 5101021517 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | ED0251A | 01 | WV | WEST VIRGINIA EDUCATION LICENSE | OTHER | UO3116 | 01 | FL | TRAINING LICENSE | OTHER |