Basic Information
| Provider Information | |||||||||
| NPI: | 1457748980 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANTILL | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 KINGS HWY | ||||||||
| Address2: | INTERNAL MEDICINE | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188132528 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1215 HADLEY RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461582907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178349618 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2015 | ||||||||
| LastUpdateDate: | 06/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | 01087036A | IN | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.