Provider Demographics
NPI:1417993668
Name:MARTIN, LINUS (MD)
Entity Type:Individual
Prefix:
First Name:LINUS
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 648
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-0648
Mailing Address - Country:US
Mailing Address - Phone:601-663-1200
Mailing Address - Fax:601-663-1379
Practice Address - Street 1:1001 HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-2161
Practice Address - Country:US
Practice Address - Phone:601-663-1200
Practice Address - Fax:601-663-1379
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16527207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122762Medicaid
MS930002646Medicare ID - Type Unspecified
MS00122762Medicaid