Provider Demographics
NPI:1043440308
Name:MARTISIUS, SAMUEL I (DO)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:I
Last Name:MARTISIUS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13355 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-2048
Mailing Address - Country:US
Mailing Address - Phone:586-759-7690
Mailing Address - Fax:
Practice Address - Street 1:13355 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-2048
Practice Address - Country:US
Practice Address - Phone:586-759-7690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018393207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101018393Medicaid