Provider Demographics
NPI:1124192737
Name:MCILVEEN, PETER F (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:F
Last Name:MCILVEEN
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 1:942 JOHNSON RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-2212
Mailing Address - Country:US
Mailing Address - Phone:336-526-3500
Mailing Address - Fax:336-526-3508
Practice Address - Street 1:942 JOHNSON RIDGE RD
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2212
Practice Address - Country:US
Practice Address - Phone:336-526-3500
Practice Address - Fax:336-526-3508
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2003-00501207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8913340Medicaid
NCH83560Medicare UPIN
NC8913340Medicaid