Provider Demographics
NPI:1730469693
Name:MARTIN EAR NOSE & THROAT CLINIC
Entity Type:Organization
Organization Name:MARTIN EAR NOSE & THROAT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-335-6163
Mailing Address - Street 1:37 DOCTORS PARK
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4956
Mailing Address - Country:US
Mailing Address - Phone:573-332-7000
Mailing Address - Fax:573-332-7005
Practice Address - Street 1:37 DOCTORS PARK
Practice Address - Street 2:SUITE 1
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4956
Practice Address - Country:US
Practice Address - Phone:573-332-7000
Practice Address - Fax:573-332-7005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8494207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200764918Medicaid
001011004Medicare PIN
A13619Medicare UPIN