Provider Demographics
NPI:1265886774
Name:THOMAS M MCGOVERN MD PLLC
Entity type:Organization
Organization Name:THOMAS M MCGOVERN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MCGOVERN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-596-7775
Mailing Address - Street 1:935 S BAXTER AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2245
Mailing Address - Country:US
Mailing Address - Phone:903-596-7775
Mailing Address - Fax:903-596-7778
Practice Address - Street 1:935 S BAXTER AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2245
Practice Address - Country:US
Practice Address - Phone:903-596-7775
Practice Address - Fax:903-596-7778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-21
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208G00000X
TXK7057208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX39010603Medicaid
TX39010603Medicaid