Provider Demographics
NPI:1164535365
Name:MARTIN, KURT (MD)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:
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 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:2601 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1031
Practice Address - Country:US
Practice Address - Phone:618-549-5361
Practice Address - Fax:618-351-4878
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-093490207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL49676OtherGHP INS. NUMBER
IL324139OtherGHP
IL370012538OtherRR MEDICARE NUMBER
IL3932056OtherBCBS OF IL
IL7210895OtherAETNA
IL027530OtherHAMP INSURANCE LNUMBER
IL279844OtherHEALTHLINK INS NUMBER
IL027530OtherHAMP INSURANCE LNUMBER
IL7210895OtherAETNA
IL279844OtherHEALTHLINK INS NUMBER
ILL55318Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL NUMBE
IL614350Medicare ID - Type UnspecifiedMEDICARE GROUP #
IL49676OtherGHP INS. NUMBER
IL324139OtherGHP