1073515805 NPI number — MARK J MARTONE MD

Table of content: MARK J MARTONE MD (NPI 1073515805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073515805 NPI number — MARK J MARTONE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTONE
Provider First Name:
MARK
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073515805
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 6TH AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56303-2735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-252-5131
Provider Business Mailing Address Fax Number:
320-240-2118

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 6TH AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CLOUD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56303-2735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-252-5131
Provider Business Practice Location Address Fax Number:
320-240-2118
Provider Enumeration Date:
08/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  38248 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 600873 . This is a "ARAZ GROUP/AMERICA'S PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9D412MA . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: CQ2388 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP25482 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 080076644 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 641314500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2114006 . This is a "FIRST HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2501025 . This is a "MEDICA HEALTH PLANS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 641314500 . This is a "MEDICAL ASSITANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110908 . This is a "U-CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1009667 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".




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