Provider Demographics
NPI:1154376788
Name:MARTIN, SAM (MD)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7663 LINDBERGH DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-2137
Mailing Address - Country:US
Mailing Address - Phone:314-743-6402
Mailing Address - Fax:
Practice Address - Street 1:2025 S BRENTWOOD BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:BRENTWOOD
Practice Address - State:MO
Practice Address - Zip Code:63144-1833
Practice Address - Country:US
Practice Address - Phone:314-918-1688
Practice Address - Fax:844-272-4251
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2005010629208VP0014X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207302605Medicaid
MO207302605Medicaid
MO931020635Medicare ID - Type Unspecified