Provider Demographics
NPI:1932110228
Name:KENNETH M. MCINTYRE MD PC
Entity Type:Organization
Organization Name:KENNETH M. MCINTYRE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:MCINTYRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-613-1829
Mailing Address - Street 1:710 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1095
Mailing Address - Country:US
Mailing Address - Phone:276-613-1829
Mailing Address - Fax:276-227-0446
Practice Address - Street 1:710 W RIDGE RD
Practice Address - Street 2:SUITE E
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1095
Practice Address - Country:US
Practice Address - Phone:276-613-1829
Practice Address - Fax:276-613-1829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231072207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty