Provider Demographics
NPI:1639310741
Name:MARTIN, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 WEXFORD DR
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:OH
Mailing Address - Zip Code:44839-3001
Mailing Address - Country:US
Mailing Address - Phone:419-602-0100
Mailing Address - Fax:419-433-5956
Practice Address - Street 1:507 WEXFORD DR
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:OH
Practice Address - Zip Code:44839-3001
Practice Address - Country:US
Practice Address - Phone:419-602-0100
Practice Address - Fax:419-433-5956
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-19
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH29518246XS1301X, 2471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography
No246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonography
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHOTH0000Medicare UPIN