Healthcare Provider Details

I. General information

NPI: 1740268556
Provider Name (Legal Business Name): KENNETH E MCINTYRE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 W CHARLESTON BLVD #160, PATIENT CARE CENTER
LAS VEGAS NV
89102-2351
US

IV. Provider business mailing address

2040 W CHARLESTON BLVD #601
LAS VEGAS NV
89102-2227
US

V. Phone/Fax

Practice location:
  • Phone: 702-671-5150
  • Fax: 702-684-6493
Mailing address:
  • Phone: 702-671-2274
  • Fax: 702-384-7506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number10314
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: