Provider Demographics
NPI:1912011818
Name:ANDERSON, ELIZABETH L (MD)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:L
Last Name:ANDERSON
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 1:34 SAVAGE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-2410
Mailing Address - Country:US
Mailing Address - Phone:252-414-2043
Mailing Address - Fax:
Practice Address - Street 1:2051 CHARLIE HALL BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5834
Practice Address - Country:US
Practice Address - Phone:843-573-2535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26106208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC26068Medicaid
I08990Medicare UPIN