MEDICARE: BRENT JAMES MCINTYRE

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	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1861866451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENT JAMES MCINTYRE

Provider Business Mailing Address
First Line	:	20 MONROE LN
Second Line	:
City	:	GROTON
State	:	CT
Zip	:	06340-2434
Country	:	US
Telephone Number	:	928-458-0193
Fax Number	:

Provider Business Practice Location Address
First Line	:	USS SPRINGFIELD (SSN 761)
Second Line	:
City	:	FPO
State	:	AA
Zip	:	09587
Country	:	US
Telephone Number	:	928-458-0193
Fax Number	:

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

Provider Enumeration Date	:	11/19/2015
Last Update Date	:	11/19/2015

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