Provider Demographics
NPI:1891729737
Name:ALLERGY, ASTHMA AND IMMUNOLOGY CLINIC, P.A.
Entity Type:Organization
Organization Name:ALLERGY, ASTHMA AND IMMUNOLOGY CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:CECKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-765-9800
Mailing Address - Street 1:4625 CHURCHILL ST
Mailing Address - Street 2:SUITE 211
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-5868
Mailing Address - Country:US
Mailing Address - Phone:651-765-9800
Mailing Address - Fax:651-765-9801
Practice Address - Street 1:4625 CHURCHILL ST
Practice Address - Street 2:SUITE 211
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-5868
Practice Address - Country:US
Practice Address - Phone:651-765-9800
Practice Address - Fax:651-765-9801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN37517500Medicaid
DB3323OtherMEDICARE RAILROAD
C03409Medicare PIN