Provider Demographics
NPI:1316120710
Name:MICHAEL K GAVIGAN DPM
Entity type:Organization
Organization Name:MICHAEL K GAVIGAN DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-563-7133
Mailing Address - Street 1:4 BARLOWS LANDING RD STE 17
Mailing Address - Street 2:P.O BOX 3227
Mailing Address - City:POCASSET
Mailing Address - State:MA
Mailing Address - Zip Code:02559-1984
Mailing Address - Country:US
Mailing Address - Phone:508-563-7133
Mailing Address - Fax:508-563-6771
Practice Address - Street 1:4 BARLOWS LANDING RD
Practice Address - Street 2:#17
Practice Address - City:POCASSET
Practice Address - State:MA
Practice Address - Zip Code:02559-1980
Practice Address - Country:US
Practice Address - Phone:508-563-7133
Practice Address - Fax:508-563-6771
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHAEL K GAVIGAN DPM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-10
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1770302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0361704Medicaid
MA1588779607OtherNPI
MA4416070001OtherDMERC
Y70831OtherBLE CROSS
MA1588779607OtherNPI
MAY70831Medicare UPIN