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NPI Code Detail

MEDICARE: MARTY JAY MORTIMER PA-C

MEDICARE: MARTY JAY MORTIMER 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
1363A00000XPhysician Assistant5601006939MI

General Provider Information

NPI Number : 1689732810
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARTY JAY MORTIMER PA-C
Provider Business Mailing Address
First Line : 100 MICHIGAN ST NE # MC845
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49503-2560
Country : US
Telephone Number : 616-486-6790
Fax Number : 616-486-6702
Provider Business Practice Location Address
First Line : 8501 MEADOW CRK
Second Line :
City : ROCKFORD
State : MI
Zip : 49341-7524
Country : US
Telephone Number : 616-267-7884
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/04/2006
Last Update Date : 02/18/2021

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