Basic Information
| Provider Information | |||||||||
| NPI: | 1760742753 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTONIOLLI | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | PROSKINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PROSKINE | ||||||||
| OtherFirstName: | MOLLY | ||||||||
| OtherMiddleName: | ELISABETH | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 830 W END CT STE 500 | ||||||||
| Address2: | |||||||||
| City: | VERNON HILLS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600611379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475228900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 830 W END CT | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | VERNON HILLS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600611365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475228900 | ||||||||
| FaxNumber: | 8476806177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2012 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036.138510 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.