Provider Demographics
NPI:1790801512
Name:PEDIATRIC & ADULT ALLERGY ASTHMA & IMMUNOLOGY SPECIALISTS, LLC
Entity Type:Organization
Organization Name:PEDIATRIC & ADULT ALLERGY ASTHMA & IMMUNOLOGY SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:S
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-422-5569
Mailing Address - Street 1:3030 LAKE AVE
Mailing Address - Street 2:SUITE 27
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5428
Mailing Address - Country:US
Mailing Address - Phone:260-422-5569
Mailing Address - Fax:260-422-6086
Practice Address - Street 1:3030 LAKE AVE
Practice Address - Street 2:SUITE 27
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5428
Practice Address - Country:US
Practice Address - Phone:260-422-5569
Practice Address - Fax:260-422-6086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty