MEDICARE: PREMILA MARTIN PT

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	225100000X	Physical Therapist	070014746	IL
2	225100000X	Physical Therapist	1303690	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04515143	OTHER	IL	BCBS PROVIDER#

General Provider Information

NPI Number	:	1154531739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PREMILA MARTIN PT

Provider Business Mailing Address
First Line	:	5819 HIGHWAY 6 STE 100A
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-4052
Country	:	US
Telephone Number	:	281-969-8922
Fax Number	:	281-969-8941

Provider Business Practice Location Address
First Line	:	5819 HIGHWAY 6 STE 100A
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-4052
Country	:	US
Telephone Number	:	713-244-8688
Fax Number	:	713-263-3235

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	01/18/2022

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Directions to “ PREMILA MARTIN PT” Practice Location

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