1821035460 NPI number — REGINA MAY MCGOVERN M.D.

Table of content: REGINA MAY MCGOVERN M.D. (NPI 1821035460)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821035460 NPI number — REGINA MAY MCGOVERN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCGOVERN
Provider First Name:
REGINA
Provider Middle Name:
MAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PLUTH
Provider Other First Name:
REGINA
Provider Other Middle Name:
MAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1821035460
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
832 GEORGIANA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ANGELES
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98362-3512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-457-0804
Provider Business Mailing Address Fax Number:
360-457-7023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
832 GEORGIANA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ANGELES
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98362-3512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-457-0804
Provider Business Practice Location Address Fax Number:
360-457-7023
Provider Enumeration Date:
06/01/2006

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: 207XS0106X , with the licence number:  MD00038187 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8251258 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200041272 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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