Basic Information
| Provider Information | |||||||||
| NPI: | 1972562486 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTONELLI-GRECO | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 109 PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIRSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439507713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406952090 | ||||||||
| FaxNumber: | 7406954116 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIRSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439507713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406952090 | ||||||||
| FaxNumber: | 7406954116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 04/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1004 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0052415000 | 05 | WV | MEDICAID | 0382688 | 05 | OH | MEDICAID |