Provider Demographics
NPI:1114004652
Name:ANTONINI, STEVEN JOHN (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:JOHN
Last Name:ANTONINI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21205 OWENS RD STE 3
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-2023
Mailing Address - Country:US
Mailing Address - Phone:815-469-2123
Mailing Address - Fax:815-469-2149
Practice Address - Street 1:21205 OWENS RD STE 3
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-2023
Practice Address - Country:US
Practice Address - Phone:815-469-2123
Practice Address - Fax:815-469-2149
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-076951208000000X
IL036076951207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09915014OtherBLUE CROSS BLUE SHIELD
IL036076951Medicaid
649420OtherMEDICARE PROV #
E43585Medicare UPIN