Provider Demographics
NPI:1417054362
Name:MCINTOSH, MARVIN LYNELL (MD)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:LYNELL
Last Name:MCINTOSH
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 1:1121 QUINDARO BLVD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66104-5331
Mailing Address - Country:US
Mailing Address - Phone:913-233-1733
Mailing Address - Fax:913-233-0055
Practice Address - Street 1:1121 QUINDARO BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66104-5331
Practice Address - Country:US
Practice Address - Phone:913-233-1733
Practice Address - Fax:913-233-0055
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0428352207Q00000X
KS04-28352207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200006440AMedicaid
KS200006440DMedicaid
KS200006440AMedicaid
KS200006440DMedicaid