Basic Information
| Provider Information | |||||||||
| NPI: | 1578521571 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCGILLIVRAY | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 W ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546159010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152844311 | ||||||||
| FaxNumber: | 7152840475 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 W ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152844311 | ||||||||
| FaxNumber: | 7152840475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 07/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 33649-21 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110253 | 01 | IN | SIHO | OTHER | 2001532 | 01 | IN | IN MEDICAL LICENSE | OTHER | 080119274 | 01 | IN | MEDICARE RAILROAD | OTHER | 000000089960 | 01 | IN | BLUE CROSS ANTHEM | OTHER | 1000772951 | 05 | WI | MEDICAID |