MEDICARE: MR. MARVIN LYNELL MCINTOSH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	0428352	KS
2	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	04-28352	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417054362
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARVIN LYNELL MCINTOSH MD

Provider Business Mailing Address
First Line	:	1121 QUINDARO BLVD
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66104-5331
Country	:	US
Telephone Number	:	913-233-1733
Fax Number	:	913-233-0055

Provider Business Practice Location Address
First Line	:	1121 QUINDARO BLVD
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66104-5331
Country	:	US
Telephone Number	:	913-233-1733
Fax Number	:	913-233-0055

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	06/05/2012

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