Provider Demographics
NPI:1790354249
Name:MARTIN, KATHRYN MICHELLE
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MICHELLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 ASHLEY AVENUE
Mailing Address - Street 2:ROOM 202 MAIN HOSPITAL, MSC333
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:169 ASHLEY AVENUE
Practice Address - Street 2:ROOM 202 MAIN HOSPITAL, MSC333
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8908
Practice Address - Country:US
Practice Address - Phone:843-792-7108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-20
Last Update Date:2021-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL86293207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology