Provider Demographics
NPI:1699862060
Name:MCILROY, RICHARD HARRY JR (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:HARRY
Last Name:MCILROY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 NORTH 800 WEST
Mailing Address - Street 2:
Mailing Address - City:TETONIA
Mailing Address - State:ID
Mailing Address - Zip Code:83452
Mailing Address - Country:US
Mailing Address - Phone:208-456-0984
Mailing Address - Fax:
Practice Address - Street 1:4021 S 700 E
Practice Address - Street 2:SUITE 300
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2192
Practice Address - Country:US
Practice Address - Phone:800-328-3048
Practice Address - Fax:801-264-6463
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9155174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12024Medicaid