Provider Demographics
NPI:1215080049
Name:MCINTOSH, CHARLES (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MCINTOSH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 ROYAL BIRKDALE DR.
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-9597
Mailing Address - Country:US
Mailing Address - Phone:937-748-1736
Mailing Address - Fax:937-748-1407
Practice Address - Street 1:405 W. GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-4796
Practice Address - Country:US
Practice Address - Phone:937-723-3210
Practice Address - Fax:937-748-1407
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004666207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0820857Medicaid
P00195301OtherRR MCR
OH000000032022OtherBCBS
OH0820857Medicaid
OH000000032022OtherBCBS
OH0759026Medicare PIN