Basic Information
Provider Information | |||||||||
NPI: | 1265450936 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCGONAGLE | ||||||||
FirstName: | JAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 99 TERRACE ST | ||||||||
Address2: |   | ||||||||
City: | KEENE | ||||||||
State: | NH | ||||||||
PostalCode: | 034313210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6033583927 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | ONE VERNEY DRIVE | ||||||||
Address2: | CMRC | ||||||||
City: | GREENFIELD | ||||||||
State: | NH | ||||||||
PostalCode: | 034311719 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6035473311 | ||||||||
FaxNumber: | 6035473232 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2006 | ||||||||
LastUpdateDate: | 08/07/2013 | ||||||||
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 | 208000000X | 9425 | NH | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 0420010669 | VT | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080P0008X | 9425 | NH | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities |
ID Information
ID | Type | State | Issuer | Description | 30008409 | 05 | NH |   | MEDICAID | ORE3780 | 05 | VT |   | MEDICAID |