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 15 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 Field Definition 1
1 NPI 1063659225 The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
2 Entity Type Code 1 Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
3 Provider Last Name Legal Name VENDRAME The last name of the provider. If the provider is an individual, this is the legal name.
4 Provider First Name MARTINA The first name of the provider, if the provider is an individual.
5 Provider Name Prefix Text DR. The name prefix or salutation of the provider if the provider is an individual; for example, Mr., Mrs., or Corporal.
6 Provider Credential Text MD PHD The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS.
7 Provider First Line Business Practice Location Address 1811 EDWINA DR The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
8 Provider Business Practice Location Address City Name VIDALIA The city name in the location address of the provider being identified.
9 Provider Business Practice Location Address State Name GA The State code in the location of the provider being identified.
10 Provider Business Practice Location Address Postal Code 304748963 The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
11 Provider Business Practice Location Address Country Code If outside U S US The country code in the location address of the provider being identified.
12 Provider Business Practice Location Address Telephone Number 9125380003 The telephone number associated with the location address of the provider being identified.
13 Provider Business Practice Location Address Fax Number 9125387444 The fax number associated with the location address of the provider being identified.
14 Provider Enumeration Date 1/9/2009 The date the provider was assigned a unique identifier (assigned an NPI).
15 Last Update Date 9/2/2014 The date that a record was last updated or changed.
16 Provider Gender Code F The code designating the provider’s gender if the provider is a person.
17 Healthcare Provider Taxonomy Code 1 204D00000X Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
18 Provider License Number 1 36129378 The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
19 Provider License Number State Code 1 IL The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
20 Healthcare Provider Primary Taxonomy Switch 1 N
21 Healthcare Provider Taxonomy Code 2 207RS0012X
22 Provider License Number 2 36129378 The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
23 Provider License Number State Code 2 IL The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
24 Healthcare Provider Primary Taxonomy Switch 2 N
25 Healthcare Provider Taxonomy Code 3 207RS0012X
26 Provider License Number 3 070921 The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
27 Provider License Number State Code 3 GA The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
28 Healthcare Provider Primary Taxonomy Switch 3 Y
29 Other Provider Identifier 1 003139553A Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
30 Other Provider Identifier Type Code 1 05 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
31 Other Provider Identifier State 1 GA
32 Other Provider Identifier 2 202I900696 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
33 Other Provider Identifier Type Code 2 08 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
34 Other Provider Identifier State 2 GA
35 Is Sole Proprietor N Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No


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This page was last updated on: 3/10/2015

(1) Field Definition Source-. Federal Register / Vol. 69, No. 15 / Friday, January 23, 2004 / Rules and Regulations - Part II Department of Health and Human Services Office of the Secretary 45 CFR Part 162 HIPAA Administrative Simplification: Standard Unique Health Identifier for Health Care Providers; Final Rule

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