Provider Demographics
NPI:1962535765
Name:EUGENE P ANTONELL
Entity type:Organization
Organization Name:EUGENE P ANTONELL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:P
Authorized Official - Last Name:ANTONELL
Authorized Official - Suffix:
Authorized Official - Credentials:BC-HIS
Authorized Official - Phone:508-993-6467
Mailing Address - Street 1:516 HAWTHORN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:N DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-3733
Mailing Address - Country:US
Mailing Address - Phone:508-993-6467
Mailing Address - Fax:508-993-6410
Practice Address - Street 1:516 HAWTHORN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:N DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-3733
Practice Address - Country:US
Practice Address - Phone:508-993-6467
Practice Address - Fax:508-993-6410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA LIC.# 80237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1540491Medicaid