Basic Information
| Provider Information | |||||||||
| NPI: | 1679571129 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 356 24TH AVE N | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152925722 | ||||||||
| FaxNumber: | 6153466225 | ||||||||
| Practice Location | |||||||||
| Address1: | 4230 HARDING RD | ||||||||
| Address2: | SUITE 525 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372052013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153851547 | ||||||||
| FaxNumber: | 6152979161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 09/12/2011 | ||||||||
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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 | 208600000X | TN18058 | TN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3027039 | 05 | TN | MEDICAID |