Healthcare Provider Details

I. General information

NPI: 1255818555
Provider Name (Legal Business Name): KRISTY-LYN MCINTOSH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date: 06/23/2019
Reactivation Date: 07/26/2022

III. Provider practice location address

1500 S FAIRFIELD AVE
CHICAGO IL
60608-1782
US

IV. Provider business mailing address

1500 S FAIRFIELD AVE
CHICAGO IL
60608-1782
US

V. Phone/Fax

Practice location:
  • Phone: 773-257-6097
  • Fax: 401-444-4557
Mailing address:
  • Phone: 773-257-6097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberLP04367
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.079245
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: