Provider Demographics
NPI:1699771337
Name:MCGILLIVRAY, GREG A (DC)
Entity type:Individual
Prefix:DR
First Name:GREG
Middle Name:A
Last Name:MCGILLIVRAY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-3709
Mailing Address - Country:US
Mailing Address - Phone:715-392-1955
Mailing Address - Fax:715-392-1935
Practice Address - Street 1:4602 GRAND AVE STE 1000
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-2712
Practice Address - Country:US
Practice Address - Phone:218-336-3520
Practice Address - Fax:218-324-6097
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3296111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
350055889OtherRAILROAD MEDICARE
MN63G94MCOtherBCBS
4442055OtherAMERICAN CHIROPRACTIC NET
MN616826400Medicaid
U57871Medicare UPIN
350003290Medicare ID - Type Unspecified