Provider Demographics
NPI:1326183757
Name:CARROLL M. MARTIN, M.D.,S.C.
Entity Type:Organization
Organization Name:CARROLL M. MARTIN, M.D.,S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARROLL
Authorized Official - Middle Name:MCKINLEY
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:262-656-8895
Mailing Address - Street 1:6308 8TH AVE
Mailing Address - Street 2:SUITE 3030
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5031
Mailing Address - Country:US
Mailing Address - Phone:262-656-8895
Mailing Address - Fax:262-656-8898
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:SUITE 3030
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5031
Practice Address - Country:US
Practice Address - Phone:262-656-8895
Practice Address - Fax:262-656-8898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20424207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31167300Medicaid