Healthcare Provider Details

I. General information

NPI: 1770518540
Provider Name (Legal Business Name): THOMAS M MCGOREY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 01/18/2021
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 REMMEL DR
JOHNSON CREEK WI
53094-8511
US

IV. Provider business mailing address

147 W ROCKWELL ST
JEFFERSON WI
53549-2048
US

V. Phone/Fax

Practice location:
  • Phone: 920-674-6255
  • Fax: 920-674-5288
Mailing address:
  • Phone: 920-674-6255
  • Fax: 920-674-5288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38070-20
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number38070-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: