Basic Information
| Provider Information | |||||||||
| NPI: | 1811995558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARTIN | ||||||||
| OtherFirstName: | STEVE | ||||||||
| OtherMiddleName: | DOUGLAS | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 635283 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594260800 | ||||||||
| FaxNumber: | 8594264140 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL VILLAGE DRIVE | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593012000 | ||||||||
| FaxNumber: | 8594264140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
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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 | 363L00000X | 07307 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | NP-07307 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 3002999 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0562617 | 01 | KY | MEDICARE | OTHER | 0369211 | 01 | KY | MEDICARE | OTHER | 611300608058 | 01 | OH | CARESOURCE | OTHER | 78003274 | 05 | KY | MEDICAID | 0369017 | 01 | KY | MEDICARE | OTHER |