Provider Demographics
NPI:1639169618
Name:ANTONELLI, LISA F (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:F
Last Name:ANTONELLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 DORCHESTER AVENUE
Mailing Address - Street 2:SMG - CARNEY HOSPITAL
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124
Mailing Address - Country:US
Mailing Address - Phone:617-296-4000
Mailing Address - Fax:617-474-3860
Practice Address - Street 1:2100 DORCHESTER AVENUE
Practice Address - Street 2:SMG - CARNEY HOSPITAL
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124
Practice Address - Country:US
Practice Address - Phone:617-296-4000
Practice Address - Fax:617-474-3860
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA72272207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3060284Medicaid
MAJ09499OtherBCBS
MA60264OtherHPHC
MA755370OtherTUFTS
MA60264OtherHPHC
MA755370OtherTUFTS