Provider Demographics
NPI:1487660015
Name:MARTIN, ANN MARIE (AUD CCCA MS BS)
Entity Type:Individual
Prefix:DR
First Name:ANN MARIE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:AUD CCCA MS BS
Other - Prefix:MS
Other - First Name:ANNMARIE
Other - Middle Name:
Other - Last Name:ILCZYSZYN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:8403 WOODBOX RD
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-9416
Mailing Address - Country:US
Mailing Address - Phone:315-751-3142
Mailing Address - Fax:
Practice Address - Street 1:5100 W TAFT RD
Practice Address - Street 2:SUITE 4L
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3807
Practice Address - Country:US
Practice Address - Phone:315-452-2124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002090207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00561353Medicaid
NYRB1470Medicare PIN