Provider Demographics
NPI:1275547689
Name:MARTY, PHILLIP MARK (DC)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:MARK
Last Name:MARTY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 SECOND STREET
Mailing Address - Street 2:STE 200
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331
Mailing Address - Country:US
Mailing Address - Phone:952-474-4121
Mailing Address - Fax:952-474-8391
Practice Address - Street 1:464 SECOND STREET
Practice Address - Street 2:STE 200
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331
Practice Address - Country:US
Practice Address - Phone:952-474-4121
Practice Address - Fax:952-474-8391
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2470111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1D866MAOtherBCBS
MN1D866MAOtherBCBS