1093768988 NPI number — MARTIN MEDICAL CENTER, P.C.

Table of content: (NPI 1093768988)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093768988 NPI number — MARTIN MEDICAL CENTER, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARTIN MEDICAL CENTER, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1093768988
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
117 KENNEDY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARTIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38237-3309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-587-9511
Provider Business Mailing Address Fax Number:
877-309-6416

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 KENNEDY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARTIN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38237-3309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-587-9511
Provider Business Practice Location Address Fax Number:
877-309-6416
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAZLEWOOD
Authorized Official First Name:
TAMMY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
731-587-9511

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3371015 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2006779 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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