Basic Information
| Provider Information | |||||||||
| NPI: | 1235129222 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LISA ANTONELLI MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 TOTTEN POND RD | ||||||||
| Address2: | C O MZI | ||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024511906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818909933 | ||||||||
| FaxNumber: | 7818909950 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 CONGRESS ST | ||||||||
| Address2: | STE 2F | ||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021690908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174726953 | ||||||||
| FaxNumber: | 6177732193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ANTONELLI | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6174726953 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | J09499 | 01 | MA | BCBS | OTHER | 3060284 | 05 | MA | MEDICAID | 755370 | 01 | MA | TUFTS | OTHER |