MEDICARE: KELLIE MARTIN CRNA

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	367500000X	Certified Registered Nurse Anesthetist	4704173942	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	KM173942	OTHER	MI	BLUE CROSS OF MI

General Provider Information

NPI Number	:	1629032636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE MARTIN CRNA

Provider Business Mailing Address
First Line	:	39086 VASSAR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48313
Country	:	US
Telephone Number	:	586-532-7074
Fax Number	:

Provider Business Practice Location Address
First Line	:	22101 MOROSS
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48226
Country	:	US
Telephone Number	:	313-343-4766
Fax Number	:

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

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	07/08/2007

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Directions to “ KELLIE MARTIN CRNA” Practice Location

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