=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336547199
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN B MARTIN MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2014
-----------------------------------------------------
Last Update Date | 12/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 312 N MERAMEC AVE APT 300 312 N MERAMEC #300
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63105-3774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-725-2618
-----------------------------------------------------
Fax | 314-725-2618
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 312 N MERAMEC AVE APT 300 312 N MERAMEC #300
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63105-3774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-725-2618
-----------------------------------------------------
Fax | 314-725-2618
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. JOHN BARLOW MARTIN I
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 314-725-2618
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number | 26157
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------