Provider Demographics
NPI:1073717351
Name:NORTHWEST ALLERGY, P.C.
Entity Type:Organization
Organization Name:NORTHWEST ALLERGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:LAURIE
Authorized Official - Last Name:KWITTKEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-354-0464
Mailing Address - Street 1:PO BOX 1317
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-1317
Mailing Address - Country:US
Mailing Address - Phone:860-354-0464
Mailing Address - Fax:860-350-3268
Practice Address - Street 1:72A PARK LANE RD
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-2325
Practice Address - Country:US
Practice Address - Phone:860-354-0464
Practice Address - Fax:860-350-3268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033471207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001334713Medicaid
CTF20993Medicare UPIN
CT03000114Medicare ID - Type Unspecified