Basic Information
| Provider Information | |||||||||
| NPI: | 1083678023 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINER | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 164 SUMMIT AVE | ||||||||
| Address2: | FAIN BLDING | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029062853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017934636 | ||||||||
| FaxNumber: | 4017934639 | ||||||||
| Practice Location | |||||||||
| Address1: | 164 SUMMIT AVE | ||||||||
| Address2: | FAIN BLDING | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029062853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017934636 | ||||||||
| FaxNumber: | 4017934639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 07/09/2013 | ||||||||
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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 | 207Q00000X | 6413 | RI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MM71802 | 05 | RI | MEDICAID |