1801832480 NPI number — TAD B MARTIN PT

Table of content: TAD B MARTIN PT (NPI 1801832480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801832480 NPI number — TAD B MARTIN PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
TAD
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARTIN
Provider Other First Name:
THEODORE (TAD)
Provider Other Middle Name:
B
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1801832480
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1818 HENDERSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29201-2619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-758-2600
Provider Business Mailing Address Fax Number:
803-253-8896

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1510 RIBAUT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ROYAL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29935-1403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-524-3241
Provider Business Practice Location Address Fax Number:
843-322-3240
Provider Enumeration Date:
06/21/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  3924 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)