Provider Demographics
NPI:1366465817
Name:MCINTOSH, MELISSA J (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:J
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 736
Mailing Address - Street 2:
Mailing Address - City:PARSONS
Mailing Address - State:KS
Mailing Address - Zip Code:67357-0736
Mailing Address - Country:US
Mailing Address - Phone:620-820-5428
Mailing Address - Fax:620-820-5821
Practice Address - Street 1:510 PETER PAN RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KS
Practice Address - Zip Code:67301-7300
Practice Address - Country:US
Practice Address - Phone:620-577-4310
Practice Address - Fax:620-577-4312
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-29443208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100412310AMedicaid
OK100229360AOtherOKLAHOMA MEDICAID
KS101724OtherBLUE CROSS BLUE SHIELD
KS110236310OtherTRAVELERS MEDICARE
KS101724OtherBLUE CROSS BLUE SHIELD
OK100229360AOtherOKLAHOMA MEDICAID
KS101724Medicare ID - Type Unspecified