Provider Demographics
NPI:1124168042
Name:MARTIN, PHILIP L (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:L
Last Name:MARTIN
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 1:2801 BLUE RIDGE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6474
Mailing Address - Country:US
Mailing Address - Phone:919-571-0081
Mailing Address - Fax:919-787-3591
Practice Address - Street 1:2801 BLUE RIDGE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6474
Practice Address - Country:US
Practice Address - Phone:919-571-0081
Practice Address - Fax:919-787-3591
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19021174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC54270OtherBCBS PROVIDER #
NC561420397OtherTAX ID#
NC8954270Medicaid
NC180005116OtherRAILROAD MEDICARE
NC180005116OtherRAILROAD MEDICARE
NCC85337Medicare UPIN