MEDICARE: MARTHA RENEE COLLIER LPTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2081S0010X	Sports Medicine (Physical Medicine & Rehabilitation) Physician	9199	AL

General Provider Information

NPI Number	:	1952050775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTHA RENEE COLLIER LPTA

Provider Business Mailing Address
First Line	:	10388 ROSEWOOD LN
Second Line	:
City	:	DAPHNE
State	:	AL
Zip	:	36526-6654
Country	:	US
Telephone Number	:	251-753-4006
Fax Number	:

Provider Business Practice Location Address
First Line	:	1902 HAND AVE STE C
Second Line	:
City	:	BAY MINETTE
State	:	AL
Zip	:	36507-4113
Country	:	US
Telephone Number	:	251-239-5395
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2022
Last Update Date	:	03/20/2022

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