Provider Demographics
NPI:1982634028
Name:MCINTIRE, MARY ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:MCINTIRE
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 1:111 W CEDAR LN STE A
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-5417
Mailing Address - Country:US
Mailing Address - Phone:928-472-4675
Mailing Address - Fax:928-472-3431
Practice Address - Street 1:111 W CEDAR LN STE A
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5417
Practice Address - Country:US
Practice Address - Phone:928-472-4675
Practice Address - Fax:928-472-3431
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2015-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ47600207Q00000X
TN36832208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ863437Medicaid
TN31273OtherTLC
TN3891205Medicaid
TNP00183551OtherRAILROAD MEDICARE
TNP00183551OtherRAILROAD MEDICARE
TN3891205Medicaid