1063524460 NPI number — ANNE CATHERINE MARTIN-KO MD

Table of content: ANNE CATHERINE MARTIN-KO MD (NPI 1063524460)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063524460 NPI number — ANNE CATHERINE MARTIN-KO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN-KO
Provider First Name:
ANNE
Provider Middle Name:
CATHERINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1063524460
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
260 HOSPITAL DR
Provider Second Line Business Mailing Address:
SUITE 207
Provider Business Mailing Address City Name:
UKIAH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95482-4533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-463-8000
Provider Business Mailing Address Fax Number:
707-462-1111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
260 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
UKIAH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95482-4533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-463-3470
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: 2080A0000X , with the licence number:  MD048496L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080A0000X , with the licence number: C54981 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0366976 . This is a "CIGNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 42469 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 575394 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000853A . This is a "UPMC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 90923 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0012644510003OU , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0014521480001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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