Provider Demographics
NPI:1578521571
Name:MCGILLIVRAY, KATRINA K (DO)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:K
Last Name:MCGILLIVRAY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 W ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-9010
Mailing Address - Country:US
Mailing Address - Phone:715-284-4311
Mailing Address - Fax:715-284-0475
Practice Address - Street 1:610 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615
Practice Address - Country:US
Practice Address - Phone:715-284-4311
Practice Address - Fax:715-284-0475
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33649-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN110253OtherSIHO
IN2001532OtherIN MEDICAL LICENSE
IN080119274OtherMEDICARE RAILROAD
IN000000089960OtherBLUE CROSS ANTHEM
WI1000772951Medicaid
IN100389850AMedicaid
IN000000089960OtherBLUE CROSS ANTHEM