Provider Demographics
NPI:1679524888
Name:JAMES T. MARTIN JR. MD
Entity Type:Organization
Organization Name:JAMES T. MARTIN JR. MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARLA
Authorized Official - Middle Name:ALLISON
Authorized Official - Last Name:WINNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-572-7123
Mailing Address - Street 1:9213 UNIVERSITY BLVD STE A
Mailing Address - Street 2:TRIDENT EXECUTIVE VILLAGE
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9145
Mailing Address - Country:US
Mailing Address - Phone:843-572-7123
Mailing Address - Fax:843-572-7350
Practice Address - Street 1:9213 UNIVERSITY BLVD STE A
Practice Address - Street 2:TRIDENT EXECUTIVE VILLAGE
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9145
Practice Address - Country:US
Practice Address - Phone:843-572-7123
Practice Address - Fax:843-572-7350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9818174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC9818-3Medicaid
SC9818-3Medicaid