Basic Information
| Provider Information | |||||||||
| NPI: | 1487688917 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 FOUNTAIN PLAZA | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142022211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166918838 | ||||||||
| FaxNumber: | 7165641134 | ||||||||
| Practice Location | |||||||||
| Address1: | 3980 SHERIDAN DR | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142261727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7169292800 | ||||||||
| FaxNumber: | 7169292819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 08/19/2014 | ||||||||
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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 | 207P00000X | 183490 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00052701010 | 01 | NY | BLUE SHIELD | OTHER | 01690106 | 05 | NY | MEDICAID | 930128167 | 01 | NY | RAILROAD MEDICARE | OTHER | 01690106/4 | 05 | NY | MEDICAID |