Basic Information
| Provider Information | |||||||||
| NPI: | 1922096031 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | MARY ELLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 CIVIC CENTER BLVD, SOUTH PAVILION, 12TH FLOOR | ||||||||
| Address2: | PERELMAN CENTER FOR ADVANCED MEDICINE | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153600713 | ||||||||
| FaxNumber: | 2152143779 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 CIVIC CENTER BLVD, SOUTH PAVILION, 12TH FLOOR | ||||||||
| Address2: | PERELMAN CENTER FOR ADVANCED MEDICINE | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153600713 | ||||||||
| FaxNumber: | 2152143779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 11/03/2016 | ||||||||
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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 | 207RH0003X | MD-068066-L | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | MD068066L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 00189880400001 | 05 | PA | MEDICAID |