1487752325 NPI number — ROBERT ELLIS MCINTIRE MD

Table of content: ROBERT ELLIS MCINTIRE MD (NPI 1487752325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487752325 NPI number — ROBERT ELLIS MCINTIRE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCINTIRE
Provider First Name:
ROBERT
Provider Middle Name:
ELLIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487752325
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2050 MERCANTILE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LELAND
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28451-4053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-371-2500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3200 WATERFIELD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARNER
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-800-4400
Provider Business Practice Location Address Fax Number:
919-573-4163
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0804X , with the licence number:  G88381 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: 45105 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: ME105882 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: 2015-01804 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001782300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ91892Z . This is a "COUNTY OF SANTA CRUZ MEDICARE GROUP PTAN#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 34296500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: CA116296 . This is a "SANTA CRUZ COUNTY MEDICARE PTAN#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CA116297 . This is a "SANTA CRUZ COUNTY MEDICARE PTAN#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FHC 70042 . This is a "COUNTY OF SANTA CRUZ MEDI-CAL GROUP#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ92069Z . This is a "COUNTY OF SANTA CRUZ MEDICARE GROUP PTAN#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FHC 70044F . This is a "COUNTY OF SANTA CRUZ MEDI-CAL GROUP#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CA116295 . This is a "SANTA CRUZ COUNTY MEDICARE PTAN#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ91891Z . This is a "COUNTY OF SANTA CRUZ MEDICARE GROUP PTAN#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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