Basic Information
| Provider Information | |||||||||
| NPI: | 1558712901 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGILVERY | ||||||||
| FirstName: | TARYN | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3046 | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193550746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064525522 | ||||||||
| FaxNumber: | 8064523070 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 N 23RD ST STE C | ||||||||
| Address2: | |||||||||
| City: | CANYON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 790153058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064525522 | ||||||||
| FaxNumber: | 8064523070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2016 | ||||||||
| LastUpdateDate: | 07/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | BP10057640 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | S5016 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1C8011 | 01 | TX | MEDICARE | OTHER |