Healthcare Provider Details

I. General information

NPI: 1215958905
Provider Name (Legal Business Name): ANN C MARTY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 MEDICAL CENTER DR
MONTICELLO IL
61856-2116
US

IV. Provider business mailing address

P.O. BOX 6002
URBANA IL
61803-6002
US

V. Phone/Fax

Practice location:
  • Phone: 217-762-2518
  • Fax: 217-762-5261
Mailing address:
  • Phone: 217-383-6792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036077289
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: