Provider Demographics
NPI:1962883603
Name:MARTIN, CHAYSE BROCKMAN (DO)
Entity type:Individual
Prefix:
First Name:CHAYSE
Middle Name:BROCKMAN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 N MACOMB ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-7815
Mailing Address - Country:US
Mailing Address - Phone:734-240-1991
Mailing Address - Fax:
Practice Address - Street 1:600 WILSON CREEK RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:IN
Practice Address - Zip Code:47025-2751
Practice Address - Country:US
Practice Address - Phone:812-532-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY04805207P00000X
IN02005646A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100672380Medicaid
OH0367858Medicaid
IN300030141Medicaid