Basic Information
| Provider Information | |||||||||
| NPI: | 1396737300 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEDAGLIA | ||||||||
| FirstName: | ANTOINETTE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 BEAVER CREEK CIR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435371745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198916221 | ||||||||
| FaxNumber: | 4198933394 | ||||||||
| Practice Location | |||||||||
| Address1: | 660 BEAVER CREEK CIR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435371745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198916221 | ||||||||
| FaxNumber: | 4198933394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 03/05/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35064915 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0937651 | 05 | OH | MEDICAID | 000000141186 | 01 | OH | ANTHEM | OTHER | 01549 | 01 | OH | PHC | OTHER | 0636039 | 01 | OH | AETNA | OTHER | 12-01208 | 01 | OH | UHC | OTHER |