Healthcare Provider Details

I. General information

NPI: 1205827573
Provider Name (Legal Business Name): LISA J MCINTOSH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5716 MICHIGAN AVE
DETROIT MI
48210-3039
US

IV. Provider business mailing address

559 W GRAND BLVD
DETROIT MI
48216-2200
US

V. Phone/Fax

Practice location:
  • Phone: 313-554-1095
  • Fax: 313-899-3560
Mailing address:
  • Phone: 313-554-0485
  • Fax: 313-228-0283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301052024
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: