Provider Demographics
NPI:1336237239
Name:MARTIN, PHILIP L (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11144 TESSON FERRY RD
Mailing Address - Street 2:#205
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123
Mailing Address - Country:US
Mailing Address - Phone:314-842-8427
Mailing Address - Fax:314-842-8262
Practice Address - Street 1:11144 TESSON FERRY RD
Practice Address - Street 2:#205
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123
Practice Address - Country:US
Practice Address - Phone:314-842-8427
Practice Address - Fax:314-842-8262
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-09-17
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Provider Licenses
StateLicense IDTaxonomies
MO32044207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA10966Medicare UPIN