Provider Demographics
NPI:1073619193
Name:ALLERGY & ASTHMA CLINIC PLLC
Entity Type:Organization
Organization Name:ALLERGY & ASTHMA CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNERSHIP
Authorized Official - Prefix:
Authorized Official - First Name:KANTI
Authorized Official - Middle Name:HIRALAL
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-242-2255
Mailing Address - Street 1:814 N MACOMB ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-2930
Mailing Address - Country:US
Mailing Address - Phone:734-242-2255
Mailing Address - Fax:734-243-9261
Practice Address - Street 1:814 N MACOMB ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-2930
Practice Address - Country:US
Practice Address - Phone:734-242-2255
Practice Address - Fax:734-243-9261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032767207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1159OtherHPM
3505861161OtherBCBS
MI4447580Medicaid
4054378OtherAETNA
51988OtherOMNICARE
0586116OtherBCN
P00060252OtherRR MEDICARE
02183OtherPARAMOUNT
4054378OtherAETNA
51988OtherOMNICARE