Provider Demographics
NPI:1275519035
Name:MACGILLIVRAY, DOUGALD C (MD)
Entity Type:Individual
Prefix:
First Name:DOUGALD
Middle Name:C
Last Name:MACGILLIVRAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:887 CONGRESS ST
Practice Address - Street 2:SUITE 400
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3100
Practice Address - Country:US
Practice Address - Phone:207-774-6368
Practice Address - Fax:207-774-9388
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD14162208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME020029766OtherRR MEIDCARE
NH30009582Medicaid
ME275310099Medicaid
MEMM636101Medicare PIN
ME275310099Medicaid
NH30009582Medicaid
MEMM6361Medicare PIN