Provider Demographics
NPI:1013112630
Name:WESTSHORE ALLERGY AND IMMUNOLOGY,LLC
Entity Type:Organization
Organization Name:WESTSHORE ALLERGY AND IMMUNOLOGY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KHOLOUD
Authorized Official - Middle Name:KHALIL
Authorized Official - Last Name:WISHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-541-3081
Mailing Address - Street 1:29160 CENTER RIDGE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-5225
Mailing Address - Country:US
Mailing Address - Phone:440-835-1899
Mailing Address - Fax:440-835-1855
Practice Address - Street 1:29160 CENTER RIDGE RD
Practice Address - Street 2:SUITE A
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5225
Practice Address - Country:US
Practice Address - Phone:440-835-1899
Practice Address - Fax:440-835-1855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076434207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2468664Medicaid
OH2468664Medicaid