MEDICARE: MRS. SUZIE JEFFERIS SKINNER MPT

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	2305202321	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00337585	OTHER		MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	7801800	OTHER	VA	AETNA
4	193615	OTHER	VA	ANTHEM
5	193617	OTHER	VA	ANTHEM

General Provider Information

NPI Number	:	1912960055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUZIE JEFFERIS SKINNER MPT

Provider Business Mailing Address
First Line	:	PO BOX 421718
Second Line	:
City	:	GEORGETOWN
State	:	SC
Zip	:	29442-4203
Country	:	US
Telephone Number	:	843-652-8226
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 CROW LN STE 201
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-1663
Country	:	US
Telephone Number	:	843-727-1000
Fax Number	:

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

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	03/11/2021

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Directions to “ MRS. SUZIE JEFFERIS SKINNER MPT” Practice Location

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