Provider Demographics
NPI:1649314501
Name:MARTIN PEDIATRIC AND ADOLESCENT CLINIC, PC
Entity type:Organization
Organization Name:MARTIN PEDIATRIC AND ADOLESCENT CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-587-9542
Mailing Address - Street 1:142 MOUNT PELIA RD
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-3812
Mailing Address - Country:US
Mailing Address - Phone:731-587-9542
Mailing Address - Fax:
Practice Address - Street 1:142 MOUNT PELIA RD
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-3812
Practice Address - Country:US
Practice Address - Phone:731-587-9542
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD 185622080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3727836Medicaid