Provider Demographics
NPI:1912953191
Name:URBAN, MARTIN A (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:A
Last Name:URBAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3871 N PERRYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-8080
Mailing Address - Country:US
Mailing Address - Phone:815-397-5554
Mailing Address - Fax:815-550-0061
Practice Address - Street 1:3871 N PERRYVILLE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-8080
Practice Address - Country:US
Practice Address - Phone:815-397-5554
Practice Address - Fax:815-550-0061
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-0703802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036070380Medicaid
ILP00474Medicare ID - Type Unspecified
IL036070380Medicaid