Provider Demographics
NPI:1245250331
Name:MARTIN, TAMMY L (MD)
Entity type:Individual
Prefix:DR
First Name:TAMMY
Middle Name:L
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 1:625 S NEW BALLAS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8253
Mailing Address - Country:US
Mailing Address - Phone:314-993-5454
Mailing Address - Fax:
Practice Address - Street 1:233 CLARKSON RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2219
Practice Address - Country:US
Practice Address - Phone:636-256-8644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9H77207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00700283OtherRR MEDICARE
MOP00333756OtherRR MEDICARE
MOF93910Medicare UPIN
MO920954992Medicare PIN
MOP00700283OtherRR MEDICARE