Basic Information
| Provider Information | |||||||||
| NPI: | 1083648596 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | GARRETT | ||||||||
| MiddleName: | CLARK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5354 REYNOLDS ST | ||||||||
| Address2: | SUITE 424 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9128195999 | ||||||||
| FaxNumber: | 9128195980 | ||||||||
| Practice Location | |||||||||
| Address1: | 13901 E JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482152720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138220900 | ||||||||
| FaxNumber: | 3138220950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 10/02/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | D67934 | MD | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 4670740 | 05 | MI | MEDICAID |