Healthcare Provider Details

I. General information

NPI: 1174880447
Provider Name (Legal Business Name): RICKY LEE MARTIN JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2326 18TH ST STE 210
COLUMBUS IN
47201-5362
US

IV. Provider business mailing address

PO BOX 775383
CHICAGO IL
60677-5383
US

V. Phone/Fax

Practice location:
  • Phone: 812-372-8680
  • Fax: 812-373-5497
Mailing address:
  • Phone: 812-376-5315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10002016A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002016A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: