MEDICARE: DR. EDWARD L MARTIN D.C.

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	111N00000X	Chiropractor	2301006823	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0G31168	OTHER	MI	GROUP BLUE CROSS BLUE SHI
2	0G31169	OTHER	MI	BLUE CROSS BLUE SHIELD
3	0997552	OTHER	MI	HEALTH PLUS

General Provider Information

NPI Number	:	1700821758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWARD L MARTIN D.C.

Provider Business Mailing Address
First Line	:	5905 W ROLLING HILLS DR
Second Line	:
City	:	BRIDGEPORT
State	:	MI
Zip	:	48722-9656
Country	:	US
Telephone Number	:	989-777-8282
Fax Number	:	989-777-8680

Provider Business Practice Location Address
First Line	:	5905 W ROLLING HILLS DR
Second Line	:
City	:	BRIDGEPORT
State	:	MI
Zip	:	48722-9656
Country	:	US
Telephone Number	:	989-777-8282
Fax Number	:	989-777-8680

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

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	07/08/2007

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