Healthcare Provider Details

I. General information

NPI: 1497759450
Provider Name (Legal Business Name): THOMAS MICHAEL MARTIN RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 WINDSOR DR
BRIDGEPORT WV
26330
US

IV. Provider business mailing address

39 WINDSOR DR
BRIDGEPORT WV
26330-2807
US

V. Phone/Fax

Practice location:
  • Phone: 304-842-3137
  • Fax: 304-842-3138
Mailing address:
  • Phone: 304-842-3137
  • Fax: 304-842-3138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number000437
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: