Provider Demographics
NPI:1255653192
Name:ALLERGY CLINIC,P.A.
Entity Type:Organization
Organization Name:ALLERGY CLINIC,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYISICAN
Authorized Official - Prefix:
Authorized Official - First Name:SCOT
Authorized Official - Middle Name:J
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-972-1667
Mailing Address - Street 1:311 E MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-2923
Mailing Address - Country:US
Mailing Address - Phone:870-972-1667
Mailing Address - Fax:870-972-0466
Practice Address - Street 1:311 E MONROE AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-2923
Practice Address - Country:US
Practice Address - Phone:870-972-1667
Practice Address - Fax:870-972-0466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116452001Medicaid
AR53369OtherBCBS
AR116452001Medicaid