Provider Demographics
NPI:1922096031
Name:MARTIN, MARY ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 CIVIC CENTER BLVD, SOUTH PAVILION, 12TH FLOOR
Mailing Address - Street 2:PERELMAN CENTER FOR ADVANCED MEDICINE
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-360-0713
Mailing Address - Fax:215-214-3779
Practice Address - Street 1:3400 CIVIC CENTER BLVD, SOUTH PAVILION, 12TH FLOOR
Practice Address - Street 2:PERELMAN CENTER FOR ADVANCED MEDICINE
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-360-0713
Practice Address - Fax:215-214-3779
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-068066-L207RH0003X
PAMD068066L207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00189880400001Medicaid
G95154Medicare UPIN
PA00189880400001Medicaid