Provider Demographics
NPI:1871034462
Name:MARTIN HEALTH
Entity Type:Organization
Organization Name:MARTIN HEALTH
Other - Org Name:WEST TENNESSEE MEDICAL GROUP PRIMARY CARE MARTIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BARTLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:TEAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-512-1277
Mailing Address - Street 1:143 KENNEDY DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-3309
Mailing Address - Country:US
Mailing Address - Phone:731-587-5321
Mailing Address - Fax:731-588-3229
Practice Address - Street 1:143 KENNEDY DRIVE
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-3309
Practice Address - Country:US
Practice Address - Phone:731-587-5321
Practice Address - Fax:731-588-3229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-15
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 261QR1300X, 363L00000X
TN0000000126261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0757OtherMEDICARE PART B PTAN
TN044-3452Medicaid