Provider Demographics
NPI:1083635825
Name:MARTIN, STEPHEN RYAN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RYAN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1656 RIVERCHASE BLVD
Practice Address - Street 2:STE 2400
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2084
Practice Address - Country:US
Practice Address - Phone:803-329-5131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400569207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1083635825Medicaid
SC156958Medicaid
NC0694IOtherBLUE CROSS BLUE SHIELD NC
080177121OtherRAILROAD MEDICARE
NC0694IOtherBLUE CROSS BLUE SHIELD NC
SCF357164592Medicare PIN
080177121OtherRAILROAD MEDICARE