=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083751879
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANTHONY J ANTONUCCI M D P C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 01/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 830 PARK AVE CARILLON NURSING AND REHABILITATION CENTER
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11743-4543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-827-6689
-----------------------------------------------------
Fax | 631-673-4936
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 HENNESSEY DR
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11743-3824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-827-6689
-----------------------------------------------------
Fax | 631-673-4936
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | DR. ANTHONY J ANTONUCCI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 631-827-6689
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 170689
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------