MEDICARE: MARK MARTIN

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	225100000X	Physical Therapist	070.027848	IL

General Provider Information

NPI Number	:	1922888486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK MARTIN

Provider Business Mailing Address
First Line	:	6810 W WINDING TRL UNIT 202
Second Line	:
City	:	OAK FOREST
State	:	IL
Zip	:	60452-5210
Country	:	US
Telephone Number	:	312-342-5059
Fax Number	:

Provider Business Practice Location Address
First Line	:	6100 111TH ST
Second Line	:
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-2105
Country	:	US
Telephone Number	:	314-342-5059
Fax Number	:

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

Provider Enumeration Date	:	10/03/2023
Last Update Date	:	10/03/2023

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Directions to “ MARK MARTIN ” Practice Location

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