Healthcare Provider Details

I. General information

NPI: 1265998017
Provider Name (Legal Business Name): JEREMY D MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2019
Last Update Date: 02/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E BUSINESS WAY
CINCINNATI OH
45241-2374
US

IV. Provider business mailing address

6480 HARRISON AVE STE 201
CINCINNATI OH
45247-7961
US

V. Phone/Fax

Practice location:
  • Phone: 513-389-3666
  • Fax: 513-389-3665
Mailing address:
  • Phone: 513-389-3666
  • Fax: 513-389-3665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT017726
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: