Basic Information
| Provider Information | |||||||||
| NPI: | 1063543080 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | JEANNE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2727 PACES FERRY ROAD | ||||||||
| Address2: | SUITE 1-1100 (ATTENTION DENISE) | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4702713421 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 OGLETHORPE AVE | ||||||||
| Address2: | STE. 2500 | ||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065487909 | ||||||||
| FaxNumber: | 7065487973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 06/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 060405 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 060405 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 494634830A | 05 | GA | MEDICAID |