Provider Demographics
NPI:1376738013
Name:ALLERGY AND ASTHMA CLINIC INC
Entity Type:Organization
Organization Name:ALLERGY AND ASTHMA CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMACHANDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:PUDUPAKKAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-227-4602
Mailing Address - Street 1:528 W MARKET ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4762
Mailing Address - Country:US
Mailing Address - Phone:419-227-4602
Mailing Address - Fax:419-221-1025
Practice Address - Street 1:528 W MARKET ST
Practice Address - Street 2:SUITE 120
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4762
Practice Address - Country:US
Practice Address - Phone:419-227-4602
Practice Address - Fax:419-221-1025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35035640207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000514711OtherANTHEM BC/BS
OH2041418Medicaid
OH2041418Medicaid