1265450936 NPI number — DR. JAN MCGONAGLE M.D.

Table of content: DR. JAN MCGONAGLE M.D. (NPI 1265450936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265450936 NPI number — DR. JAN MCGONAGLE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCGONAGLE
Provider First Name:
JAN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265450936
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
99 TERRACE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEENE
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03431-3210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-358-3927
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ONE VERNEY DRIVE
Provider Second Line Business Practice Location Address:
CMRC
Provider Business Practice Location Address City Name:
GREENFIELD
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03431-1719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-547-3311
Provider Business Practice Location Address Fax Number:
603-547-3232
Provider Enumeration Date:
07/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  9425 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 0420010669 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0008X , with the licence number: 9425 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 30008409 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: ORE3780 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".