Provider Demographics
NPI:1053699017
Name:TIMOTHY A MCGILLIVRAY M.D. INC
Entity type:Organization
Organization Name:TIMOTHY A MCGILLIVRAY M.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCGILLIVRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-602-5002
Mailing Address - Street 1:748 AVENUE C
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-4841
Mailing Address - Country:US
Mailing Address - Phone:310-602-5002
Mailing Address - Fax:
Practice Address - Street 1:23600 TELO AVE STE 120
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4036
Practice Address - Country:US
Practice Address - Phone:310-602-5002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty