Basic Information
| Provider Information | |||||||||
| NPI: | 1639169618 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTONELLI | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 DORCHESTER AVENUE | ||||||||
| Address2: | SMG - CARNEY HOSPITAL | ||||||||
| City: | DORCHESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172964000 | ||||||||
| FaxNumber: | 6174743860 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 DORCHESTER AVENUE | ||||||||
| Address2: | SMG - CARNEY HOSPITAL | ||||||||
| City: | DORCHESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172964000 | ||||||||
| FaxNumber: | 6174743860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2005 | ||||||||
| LastUpdateDate: | 11/04/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 72272 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 3060284 | 05 | MA | MEDICAID | J09499 | 01 | MA | BCBS | OTHER | 60264 | 01 | MA | HPHC | OTHER | 755370 | 01 | MA | TUFTS | OTHER |