Individual
GERALD S MARTIN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
NP
Contact information
Practice address
404 S LEWIS LN, CARBONDALE, IL 62901-3547
(618) 519-9200
(618) 549-1288
Mailing address
109 CALIFORNIA ST, PO BOX 577, CARTERVILLE, IL 62918
(618) 519-9200
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
209015754
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
214881
MEDICARE GROUP PTAN
IL
Enumeration date
03/22/2017
Last updated
09/26/2022
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