Provider Demographics
NPI:1861866451
Name:MCINTYRE, BRENT JAMES
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:JAMES
Last Name:MCINTYRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MONROE LN
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-2434
Mailing Address - Country:US
Mailing Address - Phone:928-458-0193
Mailing Address - Fax:
Practice Address - Street 1:USS SPRINGFIELD (SSN 761)
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AA
Practice Address - Zip Code:09587
Practice Address - Country:US
Practice Address - Phone:928-458-0193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman