Provider Demographics
NPI:1720228851
Name:MARTIN, JEREMIAH LEE (CRNA)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:LEE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:IL
Mailing Address - Zip Code:62863-2123
Mailing Address - Country:US
Mailing Address - Phone:618-450-2480
Mailing Address - Fax:
Practice Address - Street 1:1418 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863-2638
Practice Address - Country:US
Practice Address - Phone:618-262-8621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007481367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered