Basic Information
| Provider Information | |||||||||
| NPI: | 1982634028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCINTIRE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELLEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 W CEDAR LN STE A | ||||||||
| Address2: | |||||||||
| City: | PAYSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855415417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284724675 | ||||||||
| FaxNumber: | 9284723431 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 W CEDAR LN STE A | ||||||||
| Address2: | |||||||||
| City: | PAYSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855415417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284724675 | ||||||||
| FaxNumber: | 9284723431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 10/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 47600 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | 36832 | TN | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 863437 | 05 | AZ | MEDICAID | 31273 | 01 | TN | TLC | OTHER | 3891205 | 05 | TN | MEDICAID | P00183551 | 01 | TN | RAILROAD MEDICARE | OTHER |