=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124022942
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS PINCKNEY MCILWAIN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2005
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3425 MELROSE RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-609-3700
-----------------------------------------------------
Fax | 910-609-3784
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3425 MELROSE RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-609-3700
-----------------------------------------------------
Fax | 910-609-3784
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 31174
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------