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1982702742

NPI Code Detail

MEDICARE: DR. THOMAS WILLIAM MCGOVERN M.D.

MEDICARE: DR. THOMAS WILLIAM MCGOVERN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	01052178A	IN
2	207NS0135X	Procedural Dermatology Physician	01052178A	IN
3	207ND0101X	MOHS-Micrographic Surgery Physician	01052178A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	P00060564	OTHER		MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01052178B	OTHER	IN	CSR LICENSE NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	2576	OTHER		PHP
4	5878557	OTHER		AETNA
6	000000308075	OTHER		BCBS

General Provider Information

NPI Number	:	1982702742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS WILLIAM MCGOVERN M.D.

Provider Business Mailing Address
First Line	:	7881 CARNEGIE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-5792
Country	:	US
Telephone Number	:	260-436-8000
Fax Number	:	260-432-5587

Provider Business Practice Location Address
First Line	:	7881 CARNEGIE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-5792
Country	:	US
Telephone Number	:	260-436-8000
Fax Number	:	260-432-5587

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	03/07/2023

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Directions to “ DR. THOMAS WILLIAM MCGOVERN M.D.” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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