Provider Demographics
NPI:1013902253
Name:MARTINS RUN
Entity Type:Organization
Organization Name:MARTINS RUN
Other - Org Name:MARTINS RUN
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:WISNIEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-353-7660
Mailing Address - Street 1:11 MARTINS RUN
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-1057
Mailing Address - Country:US
Mailing Address - Phone:610-353-7760
Mailing Address - Fax:610-353-4928
Practice Address - Street 1:11 MARTINS RUN
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-1057
Practice Address - Country:US
Practice Address - Phone:610-353-7760
Practice Address - Fax:610-353-4928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390102314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007769830001Medicaid
1013902253OtherNPI
=========OtherEIN
=========OtherEIN