MEDICARE: JON RADLEY MARTIN D.O.

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	207R00000X	Internal Medicine Physician	SL0519	NV

General Provider Information

NPI Number	:	1497901185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JON RADLEY MARTIN D.O.

Provider Business Mailing Address
First Line	:	620 SHADOW LANE
Second Line	:	VALLEY HOSPITAL
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4194
Country	:	US
Telephone Number	:	702-388-8436
Fax Number	:	702-388-8431

Provider Business Practice Location Address
First Line	:	620 SHADOW LANE
Second Line	:	VALLEY HOSPITAL
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4194
Country	:	US
Telephone Number	:	702-388-8436
Fax Number	:	702-388-8431

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

Provider Enumeration Date	:	08/13/2008
Last Update Date	:	08/13/2008

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