Basic Information
Provider Information | |||||||||
NPI: | 1598843518 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARTIN | ||||||||
FirstName: | MELANIE | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 602658 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282602658 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367162011 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | MEDICAL CENTER BLVD | ||||||||
Address2: |   | ||||||||
City: | WINSTON SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271570001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367135200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2006 | ||||||||
LastUpdateDate: | 06/19/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 9800326 | NC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1598843518 | 05 | NC |   | MEDICAID | 8911757 | 05 | NC |   | MEDICAID | 267252 | 01 | NC | MEDCOST | OTHER | 1598843518 | 01 | VA | VIRGINIA MEDICAID | OTHER | 11757 | 01 | NC | BCBS | OTHER | 5345685 | 01 | NC | AETNA | OTHER | 159884518 | 01 | NC | TRICARE | OTHER | 26184 | 01 | NC | PARTNERS MEDICARE | OTHER | B1928 | 01 | NC | MEDCOST | OTHER | 1840740 | 01 | NC | UNITED HEALTHCARE | OTHER | 11757 | 01 | NC | BCBS OF NC | OTHER | 1598843518 | 01 | NC | PARTNERS | OTHER | Q0032Q | 01 | SC | SC MEDICAID | OTHER |