Provider Demographics
NPI:1376834275
Name:BALDWIN, JONATHAN BRIAN (PT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:BRIAN
Last Name:BALDWIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PRATHER PARK DR STE A
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-7910
Mailing Address - Country:US
Mailing Address - Phone:843-742-5791
Mailing Address - Fax:843-742-5704
Practice Address - Street 1:100 PRATHER PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7910
Practice Address - Country:US
Practice Address - Phone:843-742-5701
Practice Address - Fax:843-742-5704
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6044225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist