Provider Demographics
NPI:1477545200
Name:DEARBORN ALLERGY & ASTHMA CLINIC PC
Entity Type:Organization
Organization Name:DEARBORN ALLERGY & ASTHMA CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-565-3565
Mailing Address - Street 1:20200 OUTER DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2634
Mailing Address - Country:US
Mailing Address - Phone:313-565-3565
Mailing Address - Fax:313-565-7723
Practice Address - Street 1:20200 OUTER DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2634
Practice Address - Country:US
Practice Address - Phone:313-565-3565
Practice Address - Fax:313-565-7723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1083483Medicaid
MI2838806Medicaid
MI0H26340OtherBLUE CROSS
MI1290003Medicaid
MI0H26340OtherBLUE CROSS
MIA76754Medicare UPIN
MI0H26340Medicare ID - Type Unspecified
MIB46304Medicare UPIN