MEDICARE: GWENEVERE CHARLES MCINTOSH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	42577	WI

General Provider Information

NPI Number	:	1487620647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWENEVERE CHARLES MCINTOSH MD

Provider Business Mailing Address
First Line	:	7974 UW HEALTH CT
Second Line	:
City	:	MIDDLETON
State	:	WI
Zip	:	53562-5531
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5249 E TERRACE DR
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53718
Country	:	US
Telephone Number	:	608-265-1295
Fax Number	:	608-265-0935

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2006
Last Update Date	:	01/12/2021

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