Basic Information
| Provider Information | |||||||||
| NPI: | 1215335716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGILVREY | ||||||||
| FirstName: | MORGAN | ||||||||
| MiddleName: | MACKENZIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | I | ||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2225 N UNION ST | ||||||||
| Address2: | |||||||||
| City: | PONCA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 746011536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803085515 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2225 N UNION ST | ||||||||
| Address2: | |||||||||
| City: | PONCA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 746011555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183085515 | ||||||||
| FaxNumber: | 5807495792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2014 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y |
No ID Information.