1659409548 NPI number — MARTIN GEORGE MARTY L.I.C.S.W.

Table of content: MARTIN GEORGE MARTY L.I.C.S.W. (NPI 1659409548)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659409548 NPI number — MARTIN GEORGE MARTY L.I.C.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTY
Provider First Name:
MARTIN
Provider Middle Name:
GEORGE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.I.C.S.W.
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:
1659409548
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 4TH AVE S
Provider Second Line Business Mailing Address:
SUITE 780N
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55415-1015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-348-8124
Provider Business Mailing Address Fax Number:
612-317-6180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 4TH AVE S
Provider Second Line Business Practice Location Address:
SUITE 780N
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55415-1015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-348-8124
Provider Business Practice Location Address Fax Number:
612-317-6180
Provider Enumeration Date:
03/01/2007

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: 1041C0700X , with the licence number:  14109 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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