Provider Demographics
NPI:1043200330
Name:MCGOVERN PHYSICAL THERAPY ASSOCIATES LLC
Entity type:Organization
Organization Name:MCGOVERN PHYSICAL THERAPY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:N
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-356-5000
Mailing Address - Street 1:350 MAIN ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-5089
Mailing Address - Country:US
Mailing Address - Phone:781-321-2727
Mailing Address - Fax:781-321-4995
Practice Address - Street 1:350 MAIN ST
Practice Address - Street 2:SUITE 205
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5089
Practice Address - Country:US
Practice Address - Phone:781-321-2727
Practice Address - Fax:781-321-4995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9964261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0327328Medicaid
MA626293OtherHARVARD PROVIDER NUMBER
MA687260OtherTUFTS
MAY61240OtherBLUE CROSS BLUE SHIELD
MA9729861Medicaid
MAPT0153Medicare PIN