Healthcare Provider Details

I. General information

NPI: 1922270768
Provider Name (Legal Business Name): AMY MARTYANOV M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 W COLLEGE AVE
MARQUETTE MI
49855-2705
US

IV. Provider business mailing address

2837 US 41 W
MARQUETTE MI
49855-2252
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-3993
  • Fax:
Mailing address:
  • Phone: 906-225-3964
  • Fax: 906-226-3875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2006018424
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberLT19894
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number51192
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number4301099870
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: