Provider Demographics
NPI:1801846142
Name:LEWIS, MARTHA S (PT)
Entity type:Individual
Prefix:MISS
First Name:MARTHA
Middle Name:S
Last Name:LEWIS
Suffix:
Gender:F
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:PO BOX 1145
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29578-1145
Mailing Address - Country:US
Mailing Address - Phone:843-293-7713
Mailing Address - Fax:
Practice Address - Street 1:106 WACCAMAW MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8989
Practice Address - Country:US
Practice Address - Phone:843-234-0015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC532225100000X
NC5562225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH0068Medicaid