Provider Demographics
NPI:1285648683
Name:TALLAHASSEE ALLERGY, ASTHMA & IMMUNOLOGY, LLC
Entity Type:Organization
Organization Name:TALLAHASSEE ALLERGY, ASTHMA & IMMUNOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:GUY
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-656-7720
Mailing Address - Street 1:PO BOX 13058
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-3058
Mailing Address - Country:US
Mailing Address - Phone:850-656-7720
Mailing Address - Fax:850-656-7729
Practice Address - Street 1:2619 CENTENNIAL BLVD STE 103
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-0590
Practice Address - Country:US
Practice Address - Phone:850-656-7720
Practice Address - Fax:850-656-7729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82516207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2622203Medicaid
FL2622203Medicaid
FLH47012Medicare UPIN