Basic Information
| Provider Information | |||||||||
| NPI: | 1881037018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | DENISON | ||||||||
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| Credential: | D.O., MA, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 WHIPPLE STREET, 3RD FLOOR | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029083258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018542504 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 593 EDDY ST | ||||||||
| Address2: | CLAVERICK 2 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018542504 | ||||||||
| FaxNumber: | 4014277795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207P00000X | 5101020571 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | DC00855 | RI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | DC00855 | 01 | RI | RI LICENSE | OTHER |