Basic Information
| Provider Information | |||||||||
| NPI: | 1396787362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEYER | ||||||||
| FirstName: | MARTY | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 OLENTANGY RIVER RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147545500 | ||||||||
| FaxNumber: | 6144579519 | ||||||||
| Practice Location | |||||||||
| Address1: | 6670 PERIMETER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147545500 | ||||||||
| FaxNumber: | 6147545501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 04/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35087041 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 35087041 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 2640619 | 05 | OH | MEDICAID | 11902607 | 01 | CAQH | OTHER |