Provider Demographics
NPI:1790877470
Name:MCGOWAN, BERNARD LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:LAWRENCE
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 1:297 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-6337
Mailing Address - Country:US
Mailing Address - Phone:508-872-4590
Mailing Address - Fax:508-872-0038
Practice Address - Street 1:297 UNION AVE
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-6337
Practice Address - Country:US
Practice Address - Phone:508-872-4590
Practice Address - Fax:508-872-0038
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA28621174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2085615Medicaid
MAB18126Medicare ID - Type Unspecified
MA2085615Medicaid