Provider Demographics
NPI:1457652992
Name:MARTHA ANN TAYLOR
Entity Type:Organization
Organization Name:MARTHA ANN TAYLOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-909-1632
Mailing Address - Street 1:105 HENDRON HILLS DR
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-3638
Mailing Address - Country:US
Mailing Address - Phone:586-909-1632
Mailing Address - Fax:
Practice Address - Street 1:105 HENDRON HILLS DR
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-3638
Practice Address - Country:US
Practice Address - Phone:586-909-1632
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01066927A207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty