Provider Demographics
NPI:1528043320
Name:MACGILVRAY, PHYLLIS DEANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:DEANNE
Last Name:MACGILVRAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:DEANNE
Other - Last Name:MCCURRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:877 W FARIS RD STE A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:864-455-7800
Practice Address - Fax:864-455-9082
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-00550207Q00000X
TXR0066207Q00000X
SC28145207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX363506201Medicaid
VT1011985Medicaid
NY02702270Medicaid
TX363506202OtherCSHCN
I45647Medicare UPIN
VT1011985Medicaid
TX363506201Medicaid