1588691224 NPI number — MICHAEL G MARTIN M.D.

Table of content: MICHAEL G MARTIN M.D. (NPI 1588691224)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588691224 NPI number — MICHAEL G MARTIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
MICHAEL
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1588691224
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
48 MEDICAL PARK DR E
Provider Second Line Business Mailing Address:
STE. 255
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35235-3400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-838-3090
Provider Business Mailing Address Fax Number:
205-838-6892

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 W SPRING ST
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
SYLACAUGA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35150-2973
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-249-2249
Provider Business Practice Location Address Fax Number:
256-249-8440
Provider Enumeration Date:
06/27/2006

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: 207X00000X , with the licence number:  18224 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000096437 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 510-96437 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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