Basic Information
| Provider Information | |||||||||
| NPI: | 1487752325 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCINTIRE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | ELLIS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 MERCANTILE DR | ||||||||
| Address2: | |||||||||
| City: | LELAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284514053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103712500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3200 WATERFIELD DR | ||||||||
| Address2: | |||||||||
| City: | GARNER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198004400 | ||||||||
| FaxNumber: | 9195734163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 02/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | G88381 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0804X | 45105 | WI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0804X | ME105882 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0804X | 2015-01804 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 001782300 | 05 | FL | MEDICAID | ZZZ91892Z | 01 | CA | COUNTY OF SANTA CRUZ MEDICARE GROUP PTAN# | OTHER | 34296500 | 05 | WI | MEDICAID | CA116296 | 01 | CA | SANTA CRUZ COUNTY MEDICARE PTAN# | OTHER | CA116297 | 01 | CA | SANTA CRUZ COUNTY MEDICARE PTAN# | OTHER | FHC 70042 | 01 | CA | COUNTY OF SANTA CRUZ MEDI-CAL GROUP# | OTHER | ZZZ92069Z | 01 | CA | COUNTY OF SANTA CRUZ MEDICARE GROUP PTAN# | OTHER | FHC 70044F | 01 | CA | COUNTY OF SANTA CRUZ MEDI-CAL GROUP# | OTHER | CA116295 | 01 | CA | SANTA CRUZ COUNTY MEDICARE PTAN# | OTHER | ZZZ91891Z | 01 | CA | COUNTY OF SANTA CRUZ MEDICARE GROUP PTAN# | OTHER |