Basic Information
| Provider Information | |||||||||
| NPI: | 1083695928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCINTYRE | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 30 HIGHWAY 91 SOUTH | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | DILLON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066831188 | ||||||||
| FaxNumber: | 4066836891 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 HIGHWAY 91 SOUTH | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | DILLON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066831188 | ||||||||
| FaxNumber: | 4066836891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 10859 | MT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10859 | 01 | MT | MONTANA LICENSE | OTHER | 0145730 | 05 | MT | MEDICAID |