Provider Demographics
NPI:1215061437
Name:MAXWELL, CRYSTAL ANTREASE (MD)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANTREASE
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 BRIDGEMILL DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29707
Mailing Address - Country:US
Mailing Address - Phone:704-594-1140
Mailing Address - Fax:219-209-5611
Practice Address - Street 1:2021 BRIDGEMILL DR
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29707
Practice Address - Country:US
Practice Address - Phone:704-594-1140
Practice Address - Fax:219-209-5611
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44539207Q00000X
SC32570207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine