Healthcare Provider Details

I. General information

NPI: 1033748728
Provider Name (Legal Business Name): STEVE MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2020
Last Update Date: 04/04/2020
Certification Date: 04/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5575 CONNER ST STE A
DETROIT MI
48213-6400
US

IV. Provider business mailing address

5575 CONNER ST STE 201
DETROIT MI
48213-6401
US

V. Phone/Fax

Practice location:
  • Phone: 888-688-4311
  • Fax: 888-681-4311
Mailing address:
  • Phone: 888-688-4311
  • Fax: 888-688-4311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number23D2179512
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: