Provider Demographics
NPI:1396912234
Name:MCNAB, MARTIN BRIGGS JR (CPO)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:BRIGGS
Last Name:MCNAB
Suffix:JR
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 E COURT ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3823
Mailing Address - Country:US
Mailing Address - Phone:815-932-8564
Mailing Address - Fax:
Practice Address - Street 1:119 E COURT ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901
Practice Address - Country:US
Practice Address - Phone:815-932-8564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213000086174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6664850002Medicare NSC
IL6664850004Medicare NSC