Provider Demographics
NPI:1770863276
Name:ALLERGY & IMMUNOLOGY CENTER PC
Entity Type:Organization
Organization Name:ALLERGY & IMMUNOLOGY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:THECKEDATH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-446-7227
Mailing Address - Street 1:1911 PALMYRA RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1574
Mailing Address - Country:US
Mailing Address - Phone:229-446-7227
Mailing Address - Fax:229-420-4365
Practice Address - Street 1:1911 PALMYRA RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1574
Practice Address - Country:US
Practice Address - Phone:229-446-7227
Practice Address - Fax:229-420-4365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-29
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045992207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300034628AMedicaid