Provider Demographics
NPI:1518902022
Name:ALLERGY & ASTHMA CARE OF W MI PC
Entity Type:Organization
Organization Name:ALLERGY & ASTHMA CARE OF W MI PC
Other - Org Name:ALLERGY CONSULTANT SERVICES PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:M
Authorized Official - Last Name:MILLAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-957-1912
Mailing Address - Street 1:1179 EAST PARIS SE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3680
Mailing Address - Country:US
Mailing Address - Phone:616-957-1912
Mailing Address - Fax:616-957-0074
Practice Address - Street 1:1179 EAST PARIS SE
Practice Address - Street 2:SUITE 150
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3680
Practice Address - Country:US
Practice Address - Phone:616-957-1912
Practice Address - Fax:616-957-0074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301071401207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI347887810Medicaid
MI347887810Medicaid
MIN99890001Medicare ID - Type Unspecified