Provider Demographics
NPI:1982702742
Name:MCGOVERN, THOMAS WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WILLIAM
Last Name:MCGOVERN
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 1:7881 CARNEGIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-5792
Mailing Address - Country:US
Mailing Address - Phone:260-436-8000
Mailing Address - Fax:260-432-5587
Practice Address - Street 1:7881 CARNEGIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-5792
Practice Address - Country:US
Practice Address - Phone:260-436-8000
Practice Address - Fax:260-432-5587
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052178A207N00000X, 207NS0135X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01052178BOtherCSR LICENSE NUMBER
IN200254690Medicaid
2576OtherPHP
5878557OtherAETNA
P00060564OtherMEDICARE RAILROAD
000000308075OtherBCBS
000000308075OtherBCBS
P00060564OtherMEDICARE RAILROAD
ING70237Medicare UPIN