Basic Information
| Provider Information | |||||||||
| NPI: | 1629033246 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANSAH | ||||||||
| FirstName: | MARTINSON | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1249 15TH ST | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046911000 | ||||||||
| FaxNumber: | 3046911693 | ||||||||
| Practice Location | |||||||||
| Address1: | 1249 15TH ST | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046911000 | ||||||||
| FaxNumber: | 3046911693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 11/02/2018 | ||||||||
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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 | 207R00000X | 21665 | WV | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35.085353 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 42883 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2490746 | 05 | OH | MEDICAID | 3810000237 | 05 | WV | MEDICAID | 64083991 | 05 | KY | MEDICAID |