Provider Demographics
NPI:1083751879
Name:ANTHONY J ANTONUCCI M D P C
Entity Type:Organization
Organization Name:ANTHONY J ANTONUCCI M D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANTONUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-827-6689
Mailing Address - Street 1:6 HENNESSEY DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3824
Mailing Address - Country:US
Mailing Address - Phone:631-827-6689
Mailing Address - Fax:631-673-4936
Practice Address - Street 1:830 PARK AVE
Practice Address - Street 2:CARILLON NURSING AND REHABILITATION CENTER
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-4543
Practice Address - Country:US
Practice Address - Phone:631-827-6689
Practice Address - Fax:631-673-4936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170689207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01048177Medicaid
NY01048177Medicaid
NYA59859Medicare UPIN