Provider Demographics
NPI:1407067705
Name:MCINTYRE, BENJAMIN C (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:C
Last Name:MCINTYRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:DEPT OF SURGERY
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5452
Mailing Address - Fax:601-815-3322
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPT OF SURGERY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5452
Practice Address - Fax:601-815-3322
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32525208200000X, 208600000X, 2086S0122X
OH57007052208600000X
MS242362086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00173530Medicaid
MS189604Medicaid
SC325259Medicaid
SCAA74671955OtherMEDICARE PTAN
MSP01702551OtherRR MEDICARE PTAN
SCAA74671955OtherMEDICARE PTAN