DR. MARTINA VENDRAME, MD PHD - NPI NUMBER 1063659225

Summary

Provider Name: DR. MARTINA VENDRAME, MD PHD

NPI Number: 1063659225

Clasification: Neuromusculoskeletal Medicine & OMM (204D00000X)

Organization: CGH MEDICAL CENTER

Address:
1811 EDWINA DR
VIDALIA, GA
ZIP 30474

Phone Number: (912) 538-0003



Detailed Information

DR. Martina Vendrame, MD PHD is a neuromusculoskeletal physician in Vidalia, GA with 14 years of experience. The provider is definition to come. The assigned NPI number for this provider is 1063659225 and is registered as an individual entity type.

The NPPES NPI record indicates the provider is a female.

The provider's business address is:

1811 EDWINA DR
VIDALIA, GA
ZIP 30474-963
Phone: (912) 538-0003
Fax: (912) 538-7444

The enumeration date for this NPI number is 1/9/2009 and was last updated on 9/2/2014.

Map - Location of Practice





Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 204D00000X Neuromusculoskeletal Medicine & OMM 36129378 IL No
2 207RS0012X Internal Medicine Sleep Medicine 36129378 IL No
3 207RS0012X Internal Medicine Sleep Medicine 070921 GA Yes

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 003139553A MEDICAID GA
2 202I900696 MEDICARE PIN GA

NPI Record

No. Field Name Field Value
1 NPI 1063659225
2 Entity Type Code 1
3 Provider Last Name Legal Name VENDRAME
4 Provider First Name MARTINA
5 Provider Name Prefix Text DR.
6 Provider Credential Text MD PHD
7 Provider First Line Business Practice Location Address 1811 EDWINA DR
8 Provider Business Practice Location Address City Name VIDALIA
9 Provider Business Practice Location Address State Name GA
10 Provider Business Practice Location Address Postal Code 304748963
11 Provider Business Practice Location Address Country Code If outside U S US
12 Provider Business Practice Location Address Telephone Number 9125380003
13 Provider Business Practice Location Address Fax Number 9125387444
14 Provider Enumeration Date 1/9/2009
15 Last Update Date 9/2/2014
16 Provider Gender Code F
17 Healthcare Provider Taxonomy Code 1 204D00000X
18 Provider License Number 1 36129378
19 Provider License Number State Code 1 IL
20 Healthcare Provider Primary Taxonomy Switch 1 N
21 Healthcare Provider Taxonomy Code 2 207RS0012X
22 Provider License Number 2 36129378
23 Provider License Number State Code 2 IL
24 Healthcare Provider Primary Taxonomy Switch 2 N
25 Healthcare Provider Taxonomy Code 3 207RS0012X
26 Provider License Number 3 070921
27 Provider License Number State Code 3 GA
28 Healthcare Provider Primary Taxonomy Switch 3 Y
29 Other Provider Identifier 1 003139553A
30 Other Provider Identifier Type Code 1 05
31 Other Provider Identifier State 1 GA
32 Other Provider Identifier 2 202I900696
33 Other Provider Identifier Type Code 2 08
34 Other Provider Identifier State 2 GA
35 Is Sole Proprietor N

Download Record

Download this NPI record in Text format: Export

Download this NPI record in Excel (CSV) format: Export

Download this NPI record in XML format: Export




This page was last updated on: 11/14/2014
All materials and services on this site are provided on an "as is" and "as available" basis without warranty of any kind. The NPI record is maintained by the National Plan & Provider Enumeration System (NPPES) and anyone may request this information and other NPPES health care provider data from HHS under The Freedom of Information Act (FOIA), Title 5 of the United States Code, section 552. To update the NPI records please contact the NPPES.