Healthcare Provider Details

I. General information

NPI: 1407067705
Provider Name (Legal Business Name): BENJAMIN C. MCINTYRE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST DEPT OF SURGERY
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST DEPT OF SURGERY
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5452
  • Fax: 601-815-3322
Mailing address:
  • Phone: 601-984-5452
  • Fax: 601-815-3322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number32525
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number57007052
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number32525
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number32525
License Number StateSC
# 5
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number24236
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: