Provider Demographics
NPI:1518001155
Name:ANTONELL, EUGENE PETER (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:PETER
Last Name:ANTONELL
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2014-12-31
Deactivation Date:2013-05-30
Deactivation Code:
Reactivation Date:2014-12-31
Provider Licenses
StateLicense IDTaxonomies
MAMA, LIC # 80237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1540491Medicaid