Provider Demographics
NPI:1740355593
Name:MARTIN, MICHELE ILLE (MD)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:ILLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 S STERLING ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-3938
Mailing Address - Country:US
Mailing Address - Phone:828-433-2564
Mailing Address - Fax:828-433-2195
Practice Address - Street 1:1000 S STERLING ST
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-3938
Practice Address - Country:US
Practice Address - Phone:828-433-2567
Practice Address - Fax:828-433-2242
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC96016672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891019FMedicaid
G45319Medicare UPIN
NC891019FMedicaid
2234540CMedicare PIN