Provider Demographics
NPI:1295934065
Name:ALLERGY ASTHMA AND IMMUNOLOGY ASSOCIATES OF TH LLC
Entity type:Organization
Organization Name:ALLERGY ASTHMA AND IMMUNOLOGY ASSOCIATES OF TH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:NAGARJUNA
Authorized Official - Middle Name:R
Authorized Official - Last Name:PONGUGOTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-234-2016
Mailing Address - Street 1:4779 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4559
Mailing Address - Country:US
Mailing Address - Phone:812-234-2016
Mailing Address - Fax:812-234-2700
Practice Address - Street 1:4779 S 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4559
Practice Address - Country:US
Practice Address - Phone:812-234-2016
Practice Address - Fax:812-234-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040096174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100252770AMedicaid
IN200060Medicare PIN
INF27507Medicare UPIN