Provider Demographics
NPI:1164624573
Name:MCGOWAN, JOHN BRADLEY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BRADLEY
Last Name:MCGOWAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-3800
Mailing Address - Fax:208-625-3801
Practice Address - Street 1:2236 N MERRITT CREEK LOOP STE A
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4960
Practice Address - Country:US
Practice Address - Phone:208-625-3800
Practice Address - Fax:208-625-3801
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9095207T00000X
IDM-15651207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP1-0023470OtherINSTITUTIONAL PERMIT