MEDICARE: DR. JOHN EDWARD MARTIN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RP1001X	Pulmonary Disease Physician	36-040469	IL
2	207RP1001X	Pulmonary Disease Physician	4301046776	MI

General Provider Information

NPI Number	:	1295734952
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN EDWARD MARTIN M.D.

Provider Business Mailing Address
First Line	:	4318 GRAND AVE
Second Line	:
City	:	WESTERN SPRINGS
State	:	IL
Zip	:	60558-1436
Country	:	US
Telephone Number	:	708-508-2038
Fax Number	:	708-246-4457

Provider Business Practice Location Address
First Line	:	4318 GRAND AVE
Second Line	:
City	:	WESTERN SPRINGS
State	:	IL
Zip	:	60558-1436
Country	:	US
Telephone Number	:	708-508-2038
Fax Number	:	708-246-4457

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	07/19/2007

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