1215080049 NPI number — CHARLES MCINTOSH DO

Table of content: CHARLES MCINTOSH DO (NPI 1215080049)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215080049 NPI number — CHARLES MCINTOSH DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCINTOSH
Provider First Name:
CHARLES
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1215080049
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
72 ROYAL BIRKDALE DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGBORO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45066-9597
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-748-1736
Provider Business Mailing Address Fax Number:
937-748-1407

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 W. GRAND AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45405-4796
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-723-3210
Provider Business Practice Location Address Fax Number:
937-748-1407
Provider Enumeration Date:
01/18/2007

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: 207P00000X , with the licence number:  34004666 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0820857 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00195301 . This is a "RR MCR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000032022 . This is a "BCBS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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