Basic Information
Provider Information | |||||||||
NPI: | 1073621199 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOVIER | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2290 | ||||||||
Address2: |   | ||||||||
City: | MANITOWOC | ||||||||
State: | WI | ||||||||
PostalCode: | 542212290 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9203206212 | ||||||||
FaxNumber: | 9206845548 | ||||||||
Practice Location | |||||||||
Address1: | 1900 WOODLAND DR | ||||||||
Address2: |   | ||||||||
City: | MANITOWOC | ||||||||
State: | WI | ||||||||
PostalCode: | 542209662 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9203206212 | ||||||||
FaxNumber: | 9206845548 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/28/2006 | ||||||||
LastUpdateDate: | 09/27/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 23432 | WI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 100003091 | 01 | WI | WEA | OTHER | 110112678 | 01 | WI | RAILROAD MEDICARE | OTHER | 9314 | 01 | WI | NETWORK HEALTH PLAN | OTHER | B53179 | 01 | WI | CIGNA | OTHER | 23432 | 01 | WI | TOUCHPOINT | OTHER | 30344000 | 05 | WI |   | MEDICAID | 390806395002 | 01 | WI | CHAMPUS | OTHER |