Healthcare Provider Details

I. General information

NPI: 1144809989
Provider Name (Legal Business Name): JOHN MCGOVERN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 YORK AVE
NEW YORK NY
10065-6007
US

IV. Provider business mailing address

199 PACIFIC ST APT 3A
BROOKLYN NY
11201-5736
US

V. Phone/Fax

Practice location:
  • Phone: 212-639-3210
  • Fax:
Mailing address:
  • Phone: 914-330-5609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: