Basic Information
| Provider Information | |||||||||
| NPI: | 1699117358 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCGOVERN | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78866 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532780001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7796967150 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1340 CHARLES ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611042200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7796968700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2013 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036-146422 | IL | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 125063364 | IL | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.