1760548366 NPI number — DR. STEPHEN JOHN ANTONELLO PH.D.

Table of content: DR. STEPHEN JOHN ANTONELLO PH.D. (NPI 1760548366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760548366 NPI number — DR. STEPHEN JOHN ANTONELLO PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANTONELLO
Provider First Name:
STEPHEN
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1760548366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 DEER TRAIL PT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENDOTA HEIGHTS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55118-2750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-688-2335
Provider Business Mailing Address Fax Number:
651-688-2669

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
66 THOMPSON AVE E
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
WEST ST PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55118-3184
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-688-2335
Provider Business Practice Location Address Fax Number:
651-688-2669
Provider Enumeration Date:
12/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  LP1390 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 103667 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 148547400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00393789 . This is a "RAILROAD MEDICARE INDIV#" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6119337 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: OE222AN . This is a "BC BS INDIVIDUAL ID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP40542 . This is a "HEALTH PARTNERS INDIVIDUA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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