Basic Information
| Provider Information | |||||||||
| NPI: | 1508841479 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANTONIO | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 18139 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276198139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198739533 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 MANNING DR | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275144220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9849741000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | 200300440 | NC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207L00000X | 200300440 | NC | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | P00662391 | 01 | NC | RAILROAD-MEDICARE | OTHER | 806746 | 01 | PARTNERS | OTHER | 10202191 | 05 | VA | MEDICAID | 5901916 | 05 | NC | MEDICAID | 7356804 | 01 | AETNA | OTHER | 140P7 | 01 | BCBS | OTHER | 182870 | 01 | MEDCOST | OTHER | 3810003225 | 05 | WV | MEDICAID | Q0044G | 05 | SC | MEDICAID |