Provider Demographics
NPI:1518091321
Name:GRAND TRAVERSE ALLERGY PC
Entity Type:Organization
Organization Name:GRAND TRAVERSE ALLERGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:WIERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-995-3657
Mailing Address - Street 1:3899 W FRONT ST STE 1
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8104
Mailing Address - Country:US
Mailing Address - Phone:231-995-3657
Mailing Address - Fax:949-437-8317
Practice Address - Street 1:3899 W FRONT ST STE 1
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-995-3657
Practice Address - Fax:949-437-8317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty