Provider Demographics
NPI:1578198396
Name:MIDWEST ALLERGY ASSOCIATES, INC.
Entity Type:Organization
Organization Name:MIDWEST ALLERGY ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:KNISLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-846-5944
Mailing Address - Street 1:8080 RAVINES EDGE CT STE 100
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-5424
Mailing Address - Country:US
Mailing Address - Phone:614-846-5944
Mailing Address - Fax:614-846-6504
Practice Address - Street 1:6275 E BROAD ST STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1504
Practice Address - Country:US
Practice Address - Phone:614-759-4730
Practice Address - Fax:614-759-4731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0064258Medicaid