Provider Demographics
NPI:1487752325
Name:MCINTIRE, ROBERT ELLIS (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ELLIS
Last Name:MCINTIRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 MERCANTILE DR
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-4053
Mailing Address - Country:US
Mailing Address - Phone:910-371-2500
Mailing Address - Fax:
Practice Address - Street 1:3200 WATERFIELD DR
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529
Practice Address - Country:US
Practice Address - Phone:919-800-4400
Practice Address - Fax:919-573-4163
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG883812084P0804X
WI451052084P0804X
FLME1058822084P0804X
NC2015-018042084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001782300Medicaid
CAZZZ91892ZOtherCOUNTY OF SANTA CRUZ MEDICARE GROUP PTAN#
WI34296500Medicaid
CACA116296OtherSANTA CRUZ COUNTY MEDICARE PTAN#
CACA116297OtherSANTA CRUZ COUNTY MEDICARE PTAN#
CAFHC 70042OtherCOUNTY OF SANTA CRUZ MEDI-CAL GROUP#
CAZZZ92069ZOtherCOUNTY OF SANTA CRUZ MEDICARE GROUP PTAN#
CAFHC 70044FOtherCOUNTY OF SANTA CRUZ MEDI-CAL GROUP#
CACA116295OtherSANTA CRUZ COUNTY MEDICARE PTAN#
CAZZZ91891ZOtherCOUNTY OF SANTA CRUZ MEDICARE GROUP PTAN#
WI34296500Medicaid
CAZZZ92069ZOtherCOUNTY OF SANTA CRUZ MEDICARE GROUP PTAN#
WI0531 45300Medicare PIN