Healthcare Provider Details

I. General information

NPI: 1467783217
Provider Name (Legal Business Name): DONALD MCGOVERN CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2010
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 E SUPERIOR ST
CHICAGO IL
60611-2654
US

IV. Provider business mailing address

4039 ELLINGTON AVE
WESTERN SPRINGS IL
60558-1206
US

V. Phone/Fax

Practice location:
  • Phone: 312-238-1000
  • Fax:
Mailing address:
  • Phone: 708-246-1835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number213.000039
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number211.000026
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: