=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366679581
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOMAS JOSEPH MARTINELLI MD A PROFESSIONAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2009
-----------------------------------------------------
Last Update Date | 06/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 413 MILL BEACH RD
-----------------------------------------------------
City | BROOKINGS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97415-9690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-464-1989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1225 MARSHALL ST STE 7
-----------------------------------------------------
City | CRESCENT CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95531-2281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-464-1989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | THOMAS JOSEPH MARTINELLI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 707-458-3563
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | G042174
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------