1730443334 NPI number — DR. JONGJIN ANNE MARTIN M.D.

Table of content: DR. JONGJIN ANNE MARTIN M.D. (NPI 1730443334)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730443334 NPI number — DR. JONGJIN ANNE MARTIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
JONGJIN
Provider Middle Name:
ANNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THOMSON
Provider Other First Name:
JONGJIN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730443334
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19640
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62794-9640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-545-8000
Provider Business Mailing Address Fax Number:
217-545-9217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 N 9TH ST
Provider Second Line Business Practice Location Address:
SUITE 6W100
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62702-5303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-545-8000
Provider Business Practice Location Address Fax Number:
217-545-9217
Provider Enumeration Date:
06/27/2012

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: 207V00000X , with the licence number:  036-139490 , 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)

  • Identifier: 036139490 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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