Basic Information
| Provider Information | |||||||||
| NPI: | 1679598361 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTINO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | LOUIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2900 16TH ST | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474213510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122751381 | ||||||||
| FaxNumber: | 8122751299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 04/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 29148 | WV | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD073595L | PA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 01071930A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001846035 | 05 | PA | MEDICAID |