Healthcare Provider Details

I. General information

NPI: 1750619243
Provider Name (Legal Business Name): SCOTT LANIER MARTIN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2009
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 SIERRA DR STE 400
GREENWOOD IN
46143-7240
US

IV. Provider business mailing address

19400 N CREEK DR
LYNWOOD IL
60411-9608
US

V. Phone/Fax

Practice location:
  • Phone: 317-528-4248
  • Fax: 317-865-8314
Mailing address:
  • Phone: 708-474-0410
  • Fax: 708-474-0328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036124986
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number02003798A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: