Provider Demographics
NPI:1578505228
Name:MARTIN MEMORIAL PHYSICIANS CORPORATION INC
Entity Type:Organization
Organization Name:MARTIN MEMORIAL PHYSICIANS CORPORATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER AND CONTRO
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-636-7416
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-781-2716
Practice Address - Street 1:200 SE HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2346
Practice Address - Country:US
Practice Address - Phone:772-223-2832
Practice Address - Fax:772-781-2716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X, 261QM1300X
FL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377282907Medicaid
FL377282901Medicaid
FL377282903Medicaid
FL377282913Medicaid
FL377282906Medicaid
FL377282920Medicaid
FL377282921Medicaid
FLCC6070OtherRR MEDICARE
FL377282917Medicaid
FL377282900Medicaid
FL377282912Medicaid
FL377282917Medicaid
FL5796180001Medicare NSC
FL33740MMedicare PIN
FL377282920Medicaid
FL33740EMedicare PIN
FL377282906Medicaid
FL377282901Medicaid
FL33740BMedicare PIN
FL33740HMedicare PIN
FL33740XMedicare PIN
FL33740HMedicare PIN
FL33740BMedicare PIN