Provider Demographics
NPI:1154531739
Name:MARTIN, PREMILA (PT)
Entity type:Individual
Prefix:
First Name:PREMILA
Middle Name:
Last Name:MARTIN
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 1:5819 HIGHWAY 6 STE 100A
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-4052
Mailing Address - Country:US
Mailing Address - Phone:281-969-8922
Mailing Address - Fax:281-969-8941
Practice Address - Street 1:5819 HIGHWAY 6 STE 100A
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-4052
Practice Address - Country:US
Practice Address - Phone:713-244-8688
Practice Address - Fax:713-263-3235
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014746225100000X
TX1303690225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04515143OtherBCBS PROVIDER#
IL04515143OtherBCBS PROVIDER#
ILR00377Medicare PIN
ILR00378Medicare PIN
IL205036003Medicare PIN
IL208010003Medicare PIN
IL0727500001Medicare NSC