Healthcare Provider Details

I. General information

NPI: 1487752325
Provider Name (Legal Business Name): ROBERT ELLIS MCINTIRE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 02/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 WATERFIELD DR
GARNER NC
27529
US

IV. Provider business mailing address

2050 MERCANTILE DR
LELAND NC
28451-4053
US

V. Phone/Fax

Practice location:
  • Phone: 919-800-4400
  • Fax: 919-573-4163
Mailing address:
  • Phone: 910-371-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberG88381
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number45105
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME105882
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2015-01804
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier001782300
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer
# 2
IdentifierZZZ91892Z
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerCOUNTY OF SANTA CRUZ MEDICARE GROUP PTAN#
# 3
Identifier34296500
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer
# 4
IdentifierCA116296
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerSANTA CRUZ COUNTY MEDICARE PTAN#
# 5
IdentifierCA116297
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerSANTA CRUZ COUNTY MEDICARE PTAN#
# 6
IdentifierFHC 70042
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerCOUNTY OF SANTA CRUZ MEDI-CAL GROUP#
# 7
IdentifierZZZ92069Z
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerCOUNTY OF SANTA CRUZ MEDICARE GROUP PTAN#
# 8
IdentifierFHC 70044F
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerCOUNTY OF SANTA CRUZ MEDI-CAL GROUP#
# 9
IdentifierCA116295
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerSANTA CRUZ COUNTY MEDICARE PTAN#
# 10
IdentifierZZZ91891Z
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerCOUNTY OF SANTA CRUZ MEDICARE GROUP PTAN#

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: