Healthcare Provider Details

I. General information

NPI: 1871034462
Provider Name (Legal Business Name): MARTIN HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2017
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 KENNEDY DRIVE
MARTIN TN
38237-3309
US

IV. Provider business mailing address

143 KENNEDY DRIVE
MARTIN TN
38237-3309
US

V. Phone/Fax

Practice location:
  • Phone: 731-587-5321
  • Fax: 731-588-3229
Mailing address:
  • Phone: 731-587-5321
  • Fax: 731-588-3229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number0000000126
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BARTLEY TEAGUE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 731-512-1277