Basic Information
| Provider Information | |||||||||
| NPI: | 1144202292 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRELLI | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD, MEDICAL DIRECTOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4478 HAVEN CT | ||||||||
| Address2: | |||||||||
| City: | ZIONSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460779217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662827905 | ||||||||
| FaxNumber: | 8007310751 | ||||||||
| Practice Location | |||||||||
| Address1: | 927 N PENNSYLVANIA ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462041020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176869779 | ||||||||
| FaxNumber: | 3176865810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 01/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0400X | IN | N | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 207L00000X | 01034546 | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 100106520 | 05 | IN | MEDICAID |