Provider Demographics
NPI:1326088634
Name:MARTIN, THOMAS (RN, CRNA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:RN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4549 RAYNOR COURT
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040
Mailing Address - Country:US
Mailing Address - Phone:513-204-5696
Mailing Address - Fax:877-284-4283
Practice Address - Street 1:2000 JOSEPH E. SANKER BOULEVARD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45212
Practice Address - Country:US
Practice Address - Phone:513-204-5696
Practice Address - Fax:877-284-4283
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH117984163W00000X
OHNA029000207L00000X
OH029000367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0763115Medicaid
KY74003724Medicaid
000000273426OtherANTHEM
IN200424830Medicaid
KY617585OtherWELLCARE
728028OtherBUCKEYE
728028OtherBUCKEYE
430079914Medicare PIN
OH0763115Medicaid
8244891Medicare PIN