=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043849367
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAILER BRETT MARTIN II DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2020
-----------------------------------------------------
Last Update Date | 09/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 HOPKINSVILLE ST
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42345-1102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-377-2440
-----------------------------------------------------
Fax | 270-377-2441
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 23229
-----------------------------------------------------
City | OWENSBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42304-3229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-688-1330
-----------------------------------------------------
Fax | 270-688-1338
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 1204
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 285252
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------