Provider Demographics
NPI:1780362368
Name:MARTIN, MITCHELL RYNE
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:RYNE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 E SANTA MARIA AVE
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-3025
Mailing Address - Country:US
Mailing Address - Phone:217-690-3240
Mailing Address - Fax:
Practice Address - Street 1:207 E SANTA MARIA AVE
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-3025
Practice Address - Country:US
Practice Address - Phone:217-690-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator