Provider Demographics
NPI:1003949298
Name:IDAHO ALLERGY & ASTHMA CLINIC PA
Entity Type:Organization
Organization Name:IDAHO ALLERGY & ASTHMA CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:E
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-529-9292
Mailing Address - Street 1:3422 S 15TH E
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8262
Mailing Address - Country:US
Mailing Address - Phone:208-529-9292
Mailing Address - Fax:208-523-2397
Practice Address - Street 1:3422 S 15TH E
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8262
Practice Address - Country:US
Practice Address - Phone:208-529-9292
Practice Address - Fax:208-523-2397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8N147OtherBLUE CROSS
IDDG4709OtherRAILROAD MEDICARE
ID0000100004631OtherBLUE SHIELD
ID002516900Medicaid
ID1113392Medicare PIN