Basic Information
| Provider Information | |||||||||
| NPI: | 1770741613 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | CLINTON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 143 LONGWATER DR | ||||||||
| Address2: | |||||||||
| City: | NORWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020611683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818785200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 143 LONGWATER DR | ||||||||
| Address2: | |||||||||
| City: | NORWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020611683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818785200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2008 | ||||||||
| LastUpdateDate: | 01/08/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 241926 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 110083548A | 05 | MA | MEDICAID | 04-2297845 | 01 | MULTI-PLAN/PHCS | OTHER | 04-2297845 | 01 | HCVM/COVENTRY/FIRST HEALTH | OTHER | 754405 | 01 | TUFTS | OTHER | 8923772 | 01 | CIGNA | OTHER | 04-2297845 | 01 | UNITED HEALTH CARE | OTHER | 04-2297845 | 01 | TRICARD | OTHER | 1770741613 | 01 | FALLON HEALTH PLAN | OTHER | 1770741613 | 01 | NEIGHBORHOOD HEALTH PLAN | OTHER | AA176065 | 01 | HARVARD PILGRIM | OTHER | J46532 | 01 | MA | BCBSMA | OTHER | 9243409 | 01 | AETNA | OTHER |