Healthcare Provider Details

I. General information

NPI: 1881931756
Provider Name (Legal Business Name): MICHAEL MARTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2013
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 MONROE ST
PETOSKEY MI
49770-2266
US

IV. Provider business mailing address

521 MONROE ST
PETOSKEY MI
49770-2266
US

V. Phone/Fax

Practice location:
  • Phone: 231-487-1900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301099289
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: