Provider Demographics
NPI:1104927037
Name:MCGOWAN, PHILLIP G (DC)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:G
Last Name:MCGOWAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 LOCUST STREET
Mailing Address - Street 2:
Mailing Address - City:ELDORADO
Mailing Address - State:IL
Mailing Address - Zip Code:62930
Mailing Address - Country:US
Mailing Address - Phone:618-273-9650
Mailing Address - Fax:618-273-9650
Practice Address - Street 1:1403 LOCUST STREET
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930
Practice Address - Country:US
Practice Address - Phone:618-273-9650
Practice Address - Fax:618-273-9650
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038003526111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08382004OtherBCBS OF ILLINOIS
T35487Medicare UPIN
IL236480Medicare ID - Type Unspecified