Provider Demographics
NPI:1700821758
Name:MARTIN, EDWARD L (DC)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5905 W ROLLING HILLS DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:MI
Mailing Address - Zip Code:48722-9656
Mailing Address - Country:US
Mailing Address - Phone:989-777-8282
Mailing Address - Fax:989-777-8680
Practice Address - Street 1:5905 W ROLLING HILLS DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:MI
Practice Address - Zip Code:48722-9656
Practice Address - Country:US
Practice Address - Phone:989-777-8282
Practice Address - Fax:989-777-8680
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006823111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G31168OtherGROUP BLUE CROSS BLUE SHI
MI0G31169OtherBLUE CROSS BLUE SHIELD
MI0997552OtherHEALTH PLUS
MI0G31168OtherGROUP BLUE CROSS BLUE SHI