Healthcare Provider Details

I. General information

NPI: 1316723059
Provider Name (Legal Business Name): RYAN THOMAS MCGOWAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2023
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 HUNTINGTON DR N STE A
ALGONQUIN IL
60102-5940
US

IV. Provider business mailing address

106 EMERSON DR
SCHAUMBURG IL
60194-3935
US

V. Phone/Fax

Practice location:
  • Phone: 847-854-5700
  • Fax: 847-854-5762
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.011789
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: