Basic Information
| Provider Information | |||||||||
| NPI: | 1457529927 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | BLAIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10700 E. GEDDES AVENUE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 E HAMPDEN AVE | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801132702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2008 | ||||||||
| LastUpdateDate: | 04/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 73301 | CO | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | 7465134-1205 | UT | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 7465134-1205 | UT | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | 56120 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 04-38620 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 28911 | NE | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD18497 | HI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 201127660A | 05 | KS | MEDICAID | 10000009363001 | 01 | UT | BCBSU | OTHER | 145450 | 01 | UT | PEHP | OTHER | 1457529927 | 05 | WY | MEDICAID | 1457529927 | 05 | MT | MEDICAID | 20062369A | 05 | OK | MEDICAID | 72231033 | 05 | NM | MEDICAID | 1457529927 | 05 | UT | MEDICAID | 81700059 | 05 | CO | MEDICAID | P01180703 | 01 | UT | RAILROAD MEDICARE | OTHER | 1137619 | 01 | UT | DMBA | OTHER | 1457529927 | 01 | UT | MOLINA HEALTHCARE | OTHER | 091605 | 05 | AZ | MEDICAID | 1457529927 | 05 | IA | MEDICAID | 107120143101 | 01 | UT | SELECTHEALTH | OTHER | 1457529927 | 01 | UT | EMI HEALTH | OTHER | 5033909 | 01 | UT | AETNA HEALTHCARE | OTHER |