Provider Demographics
NPI:1144217134
Name:MACINTYRE, MARY ROBIN (CNM, RN, NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ROBIN
Last Name:MACINTYRE
Suffix:
Gender:F
Credentials:CNM, RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-0553
Mailing Address - Fax:
Practice Address - Street 1:1415 PORTLAND AVE
Practice Address - Street 2:STE 400
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3038
Practice Address - Country:US
Practice Address - Phone:585-922-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000617-1176B00000X
NY360470-1363LX0001X
NY000617367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000924350001OtherHEALTHNOW PROVIDER ID#
NY161568690OtherEMPIRE
NY7277063OtherAETNA PROVIDER ID NUMBER
NY01874840Medicaid
NYP010000617OtherBLUE CHOICE
NY161568690OtherPOMCO PROVIDER ID#
NY1899724OtherGHI PPO PROVIDER ID#
NY7277063OtherAETNA PROVIDER ID NUMBER
S27506Medicare UPIN