Healthcare Provider Details

I. General information

NPI: 1164804381
Provider Name (Legal Business Name): ELIZABETH BRADEN SCHMIDT ANTONIO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 ASHLEY AVE ROOM 202 MAIN HOSPITAL MSC 333
CHARLESTON SC
29425-8905
US

IV. Provider business mailing address

169 ASHLEY AVE ROOM 202 MAIN HOSPITAL MSC 333
CHARLESTON SC
29425-8905
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-8972
  • Fax:
Mailing address:
  • Phone: 843-792-8972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL38394
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: