1568465102 NPI number — MARTIN CLINIC CORP

Table of content: (NPI 1568465102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568465102 NPI number — MARTIN CLINIC CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARTIN CLINIC CORP
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:
1568465102
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 689022
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37068-9022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-778-8536
Provider Business Mailing Address Fax Number:
615-628-6877

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
143 KENNEDY DR
Provider Second Line Business Practice Location Address:
SUITE A
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:
731-587-5321
Provider Business Practice Location Address Fax Number:
731-588-3229
Provider Enumeration Date:
05/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SWAW
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DIRECTOR/AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
615-778-8076

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3711712 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4049793 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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