Provider Demographics
NPI:1922069061
Name:ST. MARTIN, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:ST. MARTIN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:26850 PROVIDENCE PKWY
Mailing Address - Street 2:SUITE 505
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1209
Mailing Address - Country:US
Mailing Address - Phone:248-465-4163
Mailing Address - Fax:248-465-4359
Practice Address - Street 1:26850 PROVIDENCE PKWY
Practice Address - Street 2:SUITE 505
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1209
Practice Address - Country:US
Practice Address - Phone:248-465-4163
Practice Address - Fax:248-465-4359
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2015-11-10
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Provider Licenses
StateLicense IDTaxonomies
MI4301082441207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4883284Medicaid
I52324Medicare UPIN