MEDICARE: RICKY LEE MARTIN JR. PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	10002016A	IN
2	363A00000X	Physician Assistant	10002016A	IN

General Provider Information

NPI Number	:	1174880447
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICKY LEE MARTIN JR. PA-C

Provider Business Mailing Address
First Line	:	PO BOX 775383
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60677-5383
Country	:	US
Telephone Number	:	812-376-5315
Fax Number	:

Provider Business Practice Location Address
First Line	:	2326 18TH ST STE 210
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-5362
Country	:	US
Telephone Number	:	812-372-8680
Fax Number	:	812-373-5497

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2012
Last Update Date	:	09/06/2024

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