Basic Information
| Provider Information | |||||||||
| NPI: | 1851357131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | MARTIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 MAYFLOWER CT E | ||||||||
| Address2: | |||||||||
| City: | HOMOSASSA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344464977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524762607 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 EAST BROADWAY | ||||||||
| Address2: | ST ALEXIUS HEALTH | ||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015307000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 06/06/2018 | ||||||||
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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 | 207R00000X | 2001-89 | NM | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 10452 | NH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME0088383 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30200030 | 05 | NH | MEDICAID | AA121351 | 01 | NH | HARVARD NH | OTHER | 274736700 | 05 | FL | MEDICAID | 34097 | 01 | FL | BLUE SHIELD | OTHER | 01Y013580NH01 | 01 | NH | ANTHEM BC BS | OTHER | G1448 | 05 | NM | MEDICAID |