Provider Demographics
NPI:1558333781
Name:IMMERMAN, MARTIN LEE (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:LEE
Last Name:IMMERMAN
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 1:6525 FRANCE AVE S
Mailing Address - Street 2:PAUL LARSON OB GYN CLINIC STE 100
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-3624
Mailing Address - Country:US
Mailing Address - Phone:952-927-4021
Mailing Address - Fax:952-285-6183
Practice Address - Street 1:6525 FRANCE AVE S
Practice Address - Street 2:PAUL LARSON OB GYN CLINIC STE 100
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-3624
Practice Address - Country:US
Practice Address - Phone:952-927-4021
Practice Address - Fax:952-285-6183
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN33213207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
160001274Medicare ID - Type Unspecified
F16461Medicare UPIN