Provider Demographics
NPI:1245278415
Name:ANTIQUE, MARIA CAROLINE (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:CAROLINE
Last Name:ANTIQUE
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 1:560 MCCELLAN ROAD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-9688
Mailing Address - Country:US
Mailing Address - Phone:731-234-5717
Mailing Address - Fax:423-979-6333
Practice Address - Street 1:560 MCCELLAN ROAD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305
Practice Address - Country:US
Practice Address - Phone:731-234-5717
Practice Address - Fax:423-979-6333
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35423207P00000X, 207R00000X
TNMD35423207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3893940OtherMEDICARE
TN3893940Medicaid
4105658OtherBCBS
TN103I086585Medicare PIN
TN3893940OtherMEDICARE