Basic Information
| Provider Information | |||||||||
| NPI: | 1053871467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | DANIELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3239 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295023239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437779460 | ||||||||
| FaxNumber: | 8436783610 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 2ND LOOP RD | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295052820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437772800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2019 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 82165 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 821650 | 05 | SC | MEDICAID |