Healthcare Provider Details

I. General information

NPI: 1801807425
Provider Name (Legal Business Name): MARTIN J GILLESPIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 HOSPITAL AVE SUITE 311
DU BOIS PA
15801-1462
US

IV. Provider business mailing address

100 HOSPITAL AVE
DU BOIS PA
15801-1440
US

V. Phone/Fax

Practice location:
  • Phone: 814-375-3750
  • Fax: 814-375-9624
Mailing address:
  • Phone: 814-375-3750
  • Fax: 814-375-9624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD053745L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD053745L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: