Provider Demographics
NPI:1134243934
Name:ALLERGY AND ASTHMA HEALTHCARE CLINIC, SC
Entity type:Organization
Organization Name:ALLERGY AND ASTHMA HEALTHCARE CLINIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:G
Authorized Official - Last Name:GOZUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-838-3832
Mailing Address - Street 1:54 W COUNTRYSIDE PARKWAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:YORKVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60560
Mailing Address - Country:US
Mailing Address - Phone:847-838-3832
Mailing Address - Fax:847-838-3872
Practice Address - Street 1:54 W COUNTRYSIDE PARKWAY
Practice Address - Street 2:SUITE C
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560
Practice Address - Country:US
Practice Address - Phone:847-838-3832
Practice Address - Fax:847-838-3872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH59554Medicare UPIN
IL214908Medicare ID - Type Unspecified