Basic Information
| Provider Information | |||||||||
| NPI: | 1447243472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | IRVIN | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 12TH ST | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393014158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017034282 | ||||||||
| FaxNumber: | 6017034597 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 12TH ST | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393014158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017039231 | ||||||||
| FaxNumber: | 6017034352 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 11/07/2013 | ||||||||
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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 | 207X00000X | 12862 | MS | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 12862 | MS | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00115751 | 05 | MS | MEDICAID | 200021882 | 01 | RAIL ROAD MEDICARE | OTHER | 009504900 | 01 | AL | MEDICAID OF AL | OTHER | 73073633 | 01 | AL | BLUE CROSS OF AL | OTHER |