MEDICARE: SCOTT LANIER 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	207QS0010X	Sports Medicine (Family Medicine) Physician	036124986	IL
2	207QS0010X	Sports Medicine (Family Medicine) Physician	02003798A	IN

General Provider Information

NPI Number	:	1750619243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SCOTT LANIER MARTIN D.O.

Provider Business Mailing Address
First Line	:	19400 N CREEK DR
Second Line	:
City	:	LYNWOOD
State	:	IL
Zip	:	60411-9608
Country	:	US
Telephone Number	:	708-474-0410
Fax Number	:	708-474-0328

Provider Business Practice Location Address
First Line	:	1040 SIERRA DR
Second Line	:	STE 400
City	:	GREENWOOD
State	:	IN
Zip	:	46143-7240
Country	:	US
Telephone Number	:	317-528-4248
Fax Number	:	317-865-8314

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

Provider Enumeration Date	:	11/23/2009
Last Update Date	:	01/23/2012

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Directions to “ SCOTT LANIER MARTIN D.O.” Practice Location

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