Healthcare Provider Details

I. General information

NPI: 1083875751
Provider Name (Legal Business Name): TOM PEARCE MARTIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10900 PORTER LN
JUNCTION IL
62954-2200
US

IV. Provider business mailing address

10900 PORTER LN
JUNCTION IL
62954-2200
US

V. Phone/Fax

Practice location:
  • Phone: 618-269-4034
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number036-049331
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: