Basic Information
| Provider Information | |||||||||
| NPI: | 1205132032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 W MAIN ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | KENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442402400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306773628 | ||||||||
| FaxNumber: | 3306773626 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 W MAIN ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | KENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442402400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1800941667 | ||||||||
| FaxNumber: | 3306773626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2011 | ||||||||
| LastUpdateDate: | 04/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | 4151 | OH | N | Other Service Providers | Acupuncturist | 111N00000X | 4151 | OH | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 1841239274 | 01 | OH | PARTNERS PHYSICIAN GROUP TYPE 2 NPI # | OTHER | 3157355 | 05 | OH | MEDICAID | 9338635 | 01 | OH | PARTNERS PHYSICIAN GROUP MEDICARE GROUP # | OTHER | 2551671 | 01 | OH | PARTNERS PHYSICIAN GROUP MEDICAID GROUP # | OTHER |