Basic Information
| Provider Information | |||||||||
| NPI: | 1891992376 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12622 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816576 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 BRANDERMILL BLVD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | GAMBRILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210541690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107211507 | ||||||||
| FaxNumber: | 4107211510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2007 | ||||||||
| LastUpdateDate: | 04/01/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 0116019263 | VA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | C7-0004604 | DE | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RS0010X | D73127 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 053826400 | 05 | MD | MEDICAID | K6440003 | 01 | DC | BCBS | OTHER | 97725101 | 01 | MD | BCBS | OTHER | 8527802 | 01 | MD | AETNA HMO | OTHER | 9936846 | 01 | MD | AETNA PPO | OTHER |