Provider Demographics
NPI:1285766469
Name:PETER J. MARTIN
Entity type:Organization
Organization Name:PETER J. MARTIN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HARP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-284-2423
Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:N 115 CROSBY
Mailing Address - City:TEKOA
Mailing Address - State:WA
Mailing Address - Zip Code:99033-0629
Mailing Address - Country:US
Mailing Address - Phone:509-284-2423
Mailing Address - Fax:
Practice Address - Street 1:NORTH 115 CROSBY STREET
Practice Address - Street 2:
Practice Address - City:TEKOA
Practice Address - State:WA
Practice Address - Zip Code:99033-0629
Practice Address - Country:US
Practice Address - Phone:509-284-2423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601652856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7069875Medicaid
WA7075971Medicaid
WA503838Medicare ID - Type UnspecifiedRIVERBEND MEDICARE -RHC
WA319204900Medicare ID - Type UnspecifiedMEDICARE PART B GROUP
WA080072337Medicare ID - Type UnspecifiedRAILROAD MEDICARE
WAG319204900Medicare PIN