Basic Information
Provider Information | |||||||||
NPI: | 1386632164 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARTIN | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | ARTHUR | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 501 LAPEER AVE | ||||||||
Address2: | HEALTH DELIVERY INC | ||||||||
City: | SAGINAW | ||||||||
State: | MI | ||||||||
PostalCode: | 486071208 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897596464 | ||||||||
FaxNumber: | 9893998233 | ||||||||
Practice Location | |||||||||
Address1: | 3884 MONITOR RD | ||||||||
Address2: |   | ||||||||
City: | BAY CITY | ||||||||
State: | MI | ||||||||
PostalCode: | 487069298 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9896712000 | ||||||||
FaxNumber: | 9896714000 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2005 | ||||||||
LastUpdateDate: | 01/31/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601001218 | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1012014 | 01 |   | MCLAREN HEALTH PLAN | OTHER | 260 | 01 | MI | COMMUNITY CHOICE | OTHER | 146037 | 01 |   | GREAT LAKES HEALTH PLAN | OTHER | 1012014 | 01 |   | HEALTH ADVANTAGE PPO | OTHER | 381908328 | 01 |   | TRICARE | OTHER | 080G310660 | 01 | MI | BLUE CROSS BLUE SHIELD MI | OTHER | 2832651 | 01 | MI | MOLINA HEALTH CARE | OTHER |