Provider Demographics
NPI:1902594872
Name:ANTALIS, NICHOLAS GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:GEORGE
Last Name:ANTALIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11000 WOODLANDS TER
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-7515
Mailing Address - Country:US
Mailing Address - Phone:740-421-0752
Mailing Address - Fax:
Practice Address - Street 1:900 S CATON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5201
Practice Address - Country:US
Practice Address - Phone:667-234-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program