Healthcare Provider Details

I. General information

NPI: 1770036410
Provider Name (Legal Business Name): DEVIN ANTONOVICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2016
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 MCSWAIN DR
WEST COLUMBIA SC
29169-4825
US

IV. Provider business mailing address

9267 MEDICAL PLAZA DR STE G
N CHARLESTON SC
29406-9139
US

V. Phone/Fax

Practice location:
  • Phone: 843-797-3636
  • Fax:
Mailing address:
  • Phone: 843-797-3636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number39925
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number39925
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number39925
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMMD.39925.LL
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: