Healthcare Provider Details

I. General information

NPI: 1295739639
Provider Name (Legal Business Name): MARTINA A GREEN-MCGOWAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARTINA G MCGOWAN M.D.

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 SIMPSON AVE
ELKHART IN
46516
US

IV. Provider business mailing address

236 SIMPSON AVE
ELKHART IN
46516-4666
US

V. Phone/Fax

Practice location:
  • Phone: 574-293-0052
  • Fax: 574-293-3744
Mailing address:
  • Phone: 574-293-0052
  • Fax: 574-293-3744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01041734
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: