1184604670 NPI number — MR. CLYDE DONALD MARTIN JR. CRNA

Table of content: AIMEE ELIZABETH GREEN-BLUMSTEIN ARNP (NPI 1871040998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184604670 NPI number — MR. CLYDE DONALD MARTIN JR. CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
CLYDE
Provider Middle Name:
DONALD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
CRNA
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:
1184604670
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
68 S SERVICE RD STE 350
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11747-2358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-342-8940
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
87 MCGREGOR ST
Provider Second Line Business Practice Location Address:
STE. 1400
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03102-3765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-647-9325
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/19/2006

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: 367500000X , with the licence number:  0024166498 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 4017 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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