Basic Information
Provider Information | |||||||||
NPI: | 1982991683 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANTONIO | ||||||||
FirstName: | AILEEN ELIZABETH M | ||||||||
MiddleName: | AMPIL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ANTONIO-SANTOS | ||||||||
OtherFirstName: | AILEEN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1900 44TH ST SE | ||||||||
Address2: |   | ||||||||
City: | KENTWOOD | ||||||||
State: | MI | ||||||||
PostalCode: | 495085008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: | 6163913130 | ||||||||
Practice Location | |||||||||
Address1: | 245 CHERRY ST SE | ||||||||
Address2: | SUITE 204 | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 495034607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6166855050 | ||||||||
FaxNumber: | 6166853050 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/01/2011 | ||||||||
LastUpdateDate: | 10/19/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 4301097930 | MI | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207W00000X | 4301097930 | MI | N |   | Allopathic & Osteopathic Physicians | Ophthalmology |   |
No ID Information.