Basic Information
| Provider Information | |||||||||
| NPI: | 1962415513 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24600 W. 127TH ST | ||||||||
| Address2: | STE B325 | ||||||||
| City: | PLAINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605859502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157319100 | ||||||||
| FaxNumber: | 8157319110 | ||||||||
| Practice Location | |||||||||
| Address1: | 24600 W. 127TH ST | ||||||||
| Address2: | STE B325 | ||||||||
| City: | PLAINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605859502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157319100 | ||||||||
| FaxNumber: | 8157319110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 11/23/2010 | ||||||||
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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 | 207R00000X | 036-112004 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2084P0800X | 036-112004 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 036112004 | 05 | IL | MEDICAID | 2220936 | 01 | IL | BCBS | OTHER |