Basic Information
| Provider Information | |||||||||
| NPI: | 1578595831 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | DAN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 UNIVERSITY PKWY | ||||||||
| Address2: | SUITE 2360 | ||||||||
| City: | AIKEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 298016810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436695162 | ||||||||
| FaxNumber: | 8436674573 | ||||||||
| Practice Location | |||||||||
| Address1: | 217 DOZIER BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295014090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436695162 | ||||||||
| FaxNumber: | 8436674573 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 03/14/2013 | ||||||||
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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 | 207L00000X | 024031 | GA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 024031 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000288626F | 05 | GA | MEDICAID | G24031 | 05 | SC | MEDICAID | 550789920 | 01 | GA | TRICARE | OTHER | 000288626E | 05 | GA | MEDICAID | 048398 | 01 | GA | BCBS | OTHER | 339275 | 01 | GA | WELLCARE CMO | OTHER | 050090631 | 01 | GA | RRMEDICARE | OTHER |