Provider Demographics
NPI:1710095385
Name:ALLERGY AND ASTHMA CLINIC SC
Entity Type:Organization
Organization Name:ALLERGY AND ASTHMA CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KANELLAKES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-744-2300
Mailing Address - Street 1:229 N HAMMES AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-8100
Mailing Address - Country:US
Mailing Address - Phone:815-744-2300
Mailing Address - Fax:
Practice Address - Street 1:229 N HAMMES AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8100
Practice Address - Country:US
Practice Address - Phone:815-744-2300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL672020Medicare PIN