Healthcare Provider Details

I. General information

NPI: 1265733349
Provider Name (Legal Business Name): TERA MARTIN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2010
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6201 ROOSEVELT RD
BERWYN IL
60402-1108
US

IV. Provider business mailing address

6201 ROOSEVELT RD
BERWYN IL
60402-1108
US

V. Phone/Fax

Practice location:
  • Phone: 708-386-0845
  • Fax: 708-386-8472
Mailing address:
  • Phone: 708-386-0845
  • Fax: 708-386-8472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209.008078
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: