Basic Information
Provider Information | |||||||||
NPI: | 1982639175 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARTIN | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3146 | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462063146 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8552068406 | ||||||||
FaxNumber: | 8558238132 | ||||||||
Practice Location | |||||||||
Address1: | 1710 GUNBARREL RD | ||||||||
Address2: |   | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 374213127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4235531220 | ||||||||
FaxNumber: | 4235531231 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 03/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 24438 | TN | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 300107647 | 01 | TN | RR MCARE-CI | OTHER | 009918800 | 05 | AL |   | MEDICAID | 300107970 | 01 | TN | RR MCARE-ADR | OTHER | 3146630 | 01 | TN | PLAZA BC/BS OF TN | OTHER | 000867798 | 05 | GA |   | MEDICAID | 4017577 | 01 | TN | ADR BC/BS OF TN | OTHER |