Provider Demographics
NPI:1295792398
Name:OHIO VALLEY ALLERGY AND ASTHMA CENTER. LLC.
Entity type:Organization
Organization Name:OHIO VALLEY ALLERGY AND ASTHMA CENTER. LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MONA
Authorized Official - Middle Name:ABDELGALIL
Authorized Official - Last Name:IMAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-373-0669
Mailing Address - Street 1:PO BOX 386
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0386
Mailing Address - Country:US
Mailing Address - Phone:740-373-0669
Mailing Address - Fax:740-568-5228
Practice Address - Street 1:400 MATTHEW ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1644
Practice Address - Country:US
Practice Address - Phone:740-373-0669
Practice Address - Fax:740-568-5228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2253421Medicaid
OHG87753Medicare UPIN
OH2253421Medicaid
OH4058013Medicare ID - Type Unspecified