Provider Demographics
NPI:1184644965
Name:POHLOD-MARTIN, LYDIA A (CRNA)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:A
Last Name:POHLOD-MARTIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:A
Other - Last Name:POHLOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:11800 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3472
Mailing Address - Country:US
Mailing Address - Phone:586-573-5260
Mailing Address - Fax:586-573-5364
Practice Address - Street 1:11800 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3472
Practice Address - Country:US
Practice Address - Phone:586-573-5260
Practice Address - Fax:586-573-5364
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704115110367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4072330Medicaid
MI430046817Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MI4072330Medicaid