1366466070 NPI number — RICHARD J MARTIN MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366466070 NPI number — RICHARD J MARTIN MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

MARTIN

Provider First Name:

RICHARD

Provider Middle Name:

J

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1366466070

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/06/2011

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

24701 EUCLID AVE

Provider Second Line Business Mailing Address:

3RD FLOOR

Provider Business Mailing Address City Name:

EUCLID

Provider Business Mailing Address State Name:

OH

Provider Business Mailing Address Postal Code:

44117-1714

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

11100 EUCLID AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

CLEVELAND

Provider Business Practice Location Address State Name:

OH

Provider Business Practice Location Address Postal Code:

44106-1716

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

216-844-7700

Provider Business Practice Location Address Fax Number:

216-286-6341

Provider Enumeration Date:

07/26/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 2080N0001X , with the licence number:  35-039301 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 207L00000X , with the licence number: 35-039301 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207LP3000X , with the licence number: 35-039301 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 363812 . This is a "WELLCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 000000028304 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 000000221385 . This is a "UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 0310729 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 1019304180001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
• Identifier: 310729 . This is a "BCMH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 639973 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 000000526103 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 745947 . This is a "BUCKEYE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".