Basic Information
| Provider Information | |||||||||
| NPI: | 1013232230 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINICK | ||||||||
| FirstName: | MAISIE | ||||||||
| MiddleName: | IRENE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5300 MILITARY ROAD | ||||||||
| Address2: | MOUNT ST. MARY'S HOSPITAL | ||||||||
| City: | LEWISTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162974800 | ||||||||
| FaxNumber: | 8048288682 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 E. BROAD STREET WEST HOSPITAL - W6S | ||||||||
| Address2: | GME ADMINISTRATION POB 980257 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232980257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8048289783 | ||||||||
| FaxNumber: | 8048285613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2010 | ||||||||
| LastUpdateDate: | 03/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 9544203 | NY | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 0101257763 | VA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 272924 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.