Basic Information
| Provider Information | |||||||||
| NPI: | 1619966058 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4699 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479034699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654492732 | ||||||||
| FaxNumber: | 7654491196 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479608201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654488000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 08/12/2019 | ||||||||
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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 | 207Q00000X | 0101261638 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4301104697 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD16478 | RI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | C159538 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | E-11879 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 081939 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 01068276A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000001074701 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER | 200989300 | 05 | IN | MEDICAID |