Basic Information
| Provider Information | |||||||||
| NPI: | 1306811237 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANTILES | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14890 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122124890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185255634 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1270 BELMONT AVE | ||||||||
| Address2: | |||||||||
| City: | SCHENECTADY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123082104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183824560 | ||||||||
| FaxNumber: | 5183863619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 19155455 | NY | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081H0002X | 191554 | NY | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Hospice and Palliative Medicine | 208100000X | 191554 | NY | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 01788852 | 05 | NY | MEDICAID |