Basic Information
| Provider Information | |||||||||
| NPI: | 1275505372 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARTIN HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WEST TENNESSEE HEALTHCARE VOLUNTEER HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 161 MOUNT PELIA RD | ||||||||
| Address2: | |||||||||
| City: | MARTIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382373811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315874261 | ||||||||
| FaxNumber: | 7315883209 | ||||||||
| Practice Location | |||||||||
| Address1: | 161 MOUNT PELIA RD | ||||||||
| Address2: | |||||||||
| City: | MARTIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382373811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315874261 | ||||||||
| FaxNumber: | 7315883209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 08/29/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 7315416731 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0000000126 | TN | N | Hospitals | General Acute Care Hospital | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 01600824 | 05 | KY | MEDICAID | 0440061 | 05 | TN | MEDICAID | 25795 | 05 | TN | MEDICAID | 136771 | 05 | TN | MEDICAID | 421557527 | 01 | CHAMPUS | OTHER | 044-0061 | 05 | TN | MEDICAID | 4048507 | 01 | BCBS | OTHER |