MEDICARE: ALEXIS GONZALEZ ANTONUCCI

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	207R00000X	Internal Medicine Physician	LL95043	SC

General Provider Information

NPI Number	:	1538908371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXIS GONZALEZ ANTONUCCI

Provider Business Mailing Address
First Line	:	169 ASHLEY AVENUE
Second Line	:	ROOM 202 MAIN HOSPITAL MSC333
City	:	CHARLESTON, SC
State	:	SC
Zip	:	29425
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	169 ASHLEY AVE RM 202
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29425-5026
Country	:	US
Telephone Number	:	843-792-7365
Fax Number	:

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

Provider Enumeration Date	:	05/21/2024
Last Update Date	:	07/01/2025

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