Healthcare Provider Details

I. General information

NPI: 1811991250
Provider Name (Legal Business Name): MARTHA J SHORT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 W FAIR AVE STE 201
MARQUETTE MI
49855-5406
US

IV. Provider business mailing address

223 SANDSTONE DR
MARQUETTE MI
49855-5200
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-4500
  • Fax: 906-225-3919
Mailing address:
  • Phone: 906-228-3255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301054632
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: