Basic Information
| Provider Information | |||||||||
| NPI: | 1881670552 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONDRY | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5665 NEW NORTHSIDE DR NW | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303285831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708745400 | ||||||||
| FaxNumber: | 7708745483 | ||||||||
| Practice Location | |||||||||
| Address1: | 1613 N MCKENZIE ST | ||||||||
| Address2: | |||||||||
| City: | FOLEY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365352247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708745439 | ||||||||
| FaxNumber: | 7708745483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 03/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 33096 | WI | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207P00000X | MD.30804 | AL | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00082072 | 01 | WI | RAILROAD | OTHER | 31895500 | 05 | WI | MEDICAID |