Healthcare Provider Details

I. General information

NPI: 1609934777
Provider Name (Legal Business Name): MICHAEL GENE MCINTOSH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 DIXIE HWY SUITE 200
FT WRIGHT KY
41011
US

IV. Provider business mailing address

1717 DIXIE HWY SUITE 200
FT WRIGHT KY
41011
US

V. Phone/Fax

Practice location:
  • Phone: 839-578-4143
  • Fax: 859-344-3183
Mailing address:
  • Phone: 839-578-4143
  • Fax: 859-344-3183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number19408
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: