1467563205 NPI number — MR. MARK RANDALL MARTIN L.C.P.C.

Table of content: MR. MARK RANDALL MARTIN L.C.P.C. (NPI 1467563205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467563205 NPI number — MR. MARK RANDALL MARTIN L.C.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
MARK
Provider Middle Name:
RANDALL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
L.C.P.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467563205
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
45 BROOKSHIRE GRN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61704-6211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-663-8243
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1505 EASTLAND DR
Provider Second Line Business Practice Location Address:
EMP II LL 1000
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61701-3534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-663-1623
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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