Provider Demographics
NPI:1902845001
Name:MCINTYRE, SALLY S (MD)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:S
Last Name:MCINTYRE
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 1:2451 WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420-1893
Mailing Address - Country:US
Mailing Address - Phone:937-208-7377
Mailing Address - Fax:937-208-7375
Practice Address - Street 1:2451 WAYNE AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-1893
Practice Address - Country:US
Practice Address - Phone:937-208-7377
Practice Address - Fax:937-208-7375
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.064669207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0914925Medicaid
F53568Medicare UPIN
OH0914925Medicaid
OH0735961Medicare PIN