1073619193 NPI number — ALLERGY & ASTHMA CLINIC PLLC

Table of content: (NPI 1073619193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073619193 NPI number — ALLERGY & ASTHMA CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALLERGY & ASTHMA CLINIC PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073619193
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
814 N MACOMB ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48162-2930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-242-2255
Provider Business Mailing Address Fax Number:
734-243-9261

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
814 N MACOMB ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48162-2930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-242-2255
Provider Business Practice Location Address Fax Number:
734-243-9261
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHAH
Authorized Official First Name:
KANTI
Authorized Official Middle Name:
HIRALAL
Authorized Official Title or Position:
PARTNERSHIP
Authorized Official Telephone Number:
734-242-2255

Provider Taxonomy Codes

  • Taxonomy code: 207KA0200X , with the licence number:  4301032767 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1159 . This is a "HPM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3505861161 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4447580 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4054378 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 51988 . This is a "OMNICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0586116 . This is a "BCN" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00060252 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 02183 . This is a "PARAMOUNT" identifier . This identifiers is of the category "OTHER".




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