1780709592 NPI number — JOHN J. ANTALIS, MD INC

Table of content: (NPI 1780709592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780709592 NPI number — JOHN J. ANTALIS, MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN J. ANTALIS, MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JOHN J. ANTALIS, MD INC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780709592
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1502 DEERPATH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMBRIDGE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43725-9240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-439-3020
Provider Business Mailing Address Fax Number:
740-432-5487

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1502 DEERPATH DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43725-9240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-439-3020
Provider Business Practice Location Address Fax Number:
740-432-5487
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ANTALIS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
740-439-3020

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  35060862 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DG0782 . This is a "RRB/ MEDICARE GROUP" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 180036464 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0916003 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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