Provider Demographics
NPI:1164451936
Name:P ANTONELLI DIST INC
Entity Type:Organization
Organization Name:P ANTONELLI DIST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:ANTONELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-291-3480
Mailing Address - Street 1:4483 WHITEHALL DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-3883
Mailing Address - Country:US
Mailing Address - Phone:216-291-3480
Mailing Address - Fax:
Practice Address - Street 1:4483 WHITEHALL DR
Practice Address - Street 2:
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-3883
Practice Address - Country:US
Practice Address - Phone:216-291-3480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0872775Medicaid
OH1804015OtherIO WAIVER