Provider Demographics
NPI:1811991250
Name:SHORT, MARTHA J (MD)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:J
Last Name:SHORT
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 1:223 SANDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-5200
Mailing Address - Country:US
Mailing Address - Phone:906-228-3255
Mailing Address - Fax:
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:STE 201
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-5406
Practice Address - Country:US
Practice Address - Phone:906-225-4500
Practice Address - Fax:906-225-3919
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054632207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110E26038OtherBCBSM
MI3110839Medicaid
MI3110839Medicaid
MIOE26038Medicare ID - Type Unspecified