1063419778 NPI number — CHARLES P MCGONAGILL

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 1063419778 NPI number — CHARLES P MCGONAGILL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCGONAGILL
Provider First Name:
CHARLES
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1063419778
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1238 N PACIFIC ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINEOLA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75773-1002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-569-5432
Provider Business Mailing Address Fax Number:
903-569-2994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1238 N PACIFIC ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINEOLA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75773-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-569-5432
Provider Business Practice Location Address Fax Number:
903-569-2994
Provider Enumeration Date:
07/07/2005

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: 152W00000X , with the licence number:  1785TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 23299 . This is a "WEB-TPA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00E23A . This is a "VISION SERVICE PLAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 164523601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 22703 . This is a "ALWAYS VISION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00E23A . This is a "BENEFIT PLANNERS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00E23A . This is a "PHCS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00E23A . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 22703 . This is a "NATIONAL VISION ADMINISTRATORS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 81257Q . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 81257Q . This is a "BLUE CROSS BLUE SHIELD GOVERNMENT" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2388239 . This is a "TEXAS TRUE CHOICE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5451470001 . This is a "CIGNA GOVERNMENT SERVICES" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 60583 . This is a "SAFEGUARD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00E23A . This is a "GROUP & PENSION ADMINISTRATORS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00E23A . This is a "HEALTHFIRST TPA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5571379 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5571379 . This is a "AETNA TRS CARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00E23A . This is a "PRINCIPAL FINANCIAL GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0E23A . This is a "SUPERIOR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00E23A . This is a "VISION CARE PLAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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