Healthcare Provider Details

I. General information

NPI: 1922096031
Provider Name (Legal Business Name): MARY ELLEN MARTIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 CIVIC CENTER BLVD, SOUTH PAVILION, 12TH FLOOR PERELMAN CENTER FOR ADVANCED MEDICINE
PHILADELPHIA PA
19104
US

IV. Provider business mailing address

3400 CIVIC CENTER BLVD, SOUTH PAVILION, 12TH FLOOR PERELMAN CENTER FOR ADVANCED MEDICINE
PHILADELPHIA PA
19104
US

V. Phone/Fax

Practice location:
  • Phone: 215-360-0713
  • Fax: 215-214-3779
Mailing address:
  • Phone: 215-360-0713
  • Fax: 215-214-3779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD-068066-L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD068066L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: