Basic Information
| Provider Information | |||||||||
| NPI: | 1487639456 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | RENE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 E MARKET ST | ||||||||
| Address2: | SUITE 1N | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303753588 | ||||||||
| FaxNumber: | 3303757615 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 E MARKET ST | ||||||||
| Address2: | SUITE 1N | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303753588 | ||||||||
| FaxNumber: | 3303757615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 01/13/2012 | ||||||||
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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 | 207RG0300X | 35050748 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RC0200X | 35050748 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0614884 | 01 | OH | MEDICARE ID | OTHER | MA0614881 | 01 | OH | MEDICARE ID | OTHER | 0688788 | 05 | OH | MEDICAID |