Provider Demographics
NPI:1598423824
Name:ADVANCED ALLERGY
Entity Type:Organization
Organization Name:ADVANCED ALLERGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:978-604-1316
Mailing Address - Street 1:960 PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:MARSTONS MILLS
Mailing Address - State:MA
Mailing Address - Zip Code:02648-5708
Mailing Address - Country:US
Mailing Address - Phone:978-604-1316
Mailing Address - Fax:
Practice Address - Street 1:433 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3644
Practice Address - Country:US
Practice Address - Phone:508-362-0099
Practice Address - Fax:508-362-8811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory ImmunologyGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1043650641Medicaid
MA1558986281Medicaid
MA1316556905Medicaid