Provider Demographics
NPI:1912014325
Name:MCINTOSH, CHARLES A III (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:MCINTOSH
Suffix:III
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:PO BOX 235022
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-5022
Mailing Address - Country:US
Mailing Address - Phone:800-897-6169
Mailing Address - Fax:800-897-6170
Practice Address - Street 1:2408 BROADMOOR BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-2963
Practice Address - Country:US
Practice Address - Phone:318-410-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020634207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1962961Medicaid
LAP00092000OtherMEDICARE RAILROAD
LAF52794Medicare UPIN
LA5R591CH95Medicare ID - Type Unspecified