Provider Demographics
NPI:1396727574
Name:MARTIN, MICHAEL LEE SR (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEE
Last Name:MARTIN
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:LEE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-512-5830
Mailing Address - Fax:
Practice Address - Street 1:4120 HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29626-5321
Practice Address - Country:US
Practice Address - Phone:864-512-5830
Practice Address - Fax:864-224-4999
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21072207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC210729Medicaid