Provider Demographics
NPI:1801832480
Name:MARTIN, TAD B (PT)
Entity type:Individual
Prefix:
First Name:TAD
Middle Name:B
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:THEODORE (TAD)
Other - Middle Name:B
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1818 HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2619
Mailing Address - Country:US
Mailing Address - Phone:803-758-2600
Mailing Address - Fax:803-253-8896
Practice Address - Street 1:1510 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:PORT ROYAL
Practice Address - State:SC
Practice Address - Zip Code:29935-1403
Practice Address - Country:US
Practice Address - Phone:843-524-3241
Practice Address - Fax:843-322-3240
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3924225100000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P95142Medicare UPIN