Basic Information
| Provider Information | |||||||||
| NPI: | 1235310707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | JEREMIAH | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1735 27TH ST STE B06 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456622681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403568681 | ||||||||
| FaxNumber: | 7403537900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1711 27TH ST STE 206 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456622669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403568772 | ||||||||
| FaxNumber: | 7403542138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2007 | ||||||||
| LastUpdateDate: | 12/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 42469 | KY | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 35.127752 | OH | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 7100204410 | 05 | KY | MEDICAID | 0208938 | 05 | OH | MEDICAID |