Provider Demographics
NPI:1548096605
Name:MCINTOSH, ELISE
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLIE
Other - Middle Name:
Other - Last Name:MCINTOSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:850 BOYLSTON ST STE 320
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-2402
Mailing Address - Country:US
Mailing Address - Phone:617-732-9060
Mailing Address - Fax:
Practice Address - Street 1:850 BOYLSTON ST STE 320
Practice Address - Street 2:
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-2402
Practice Address - Country:US
Practice Address - Phone:617-732-9060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-13
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1548096605363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical