Provider Demographics
NPI:1487639456
Name:MARTIN, BRADLEY RENE (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:RENE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 DOUG WHITE DR STE 250
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4181
Mailing Address - Country:US
Mailing Address - Phone:843-236-1950
Mailing Address - Fax:843-236-1952
Practice Address - Street 1:920 DOUG WHITE DR STE 250
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4181
Practice Address - Country:US
Practice Address - Phone:843-236-1950
Practice Address - Fax:843-236-1952
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC89592207RC0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0688788Medicaid
OHMA0614881OtherMEDICARE ID
OH0614884OtherMEDICARE ID
OHMA0614881OtherMEDICARE ID