Provider Demographics
NPI:1750599569
Name:ALLERGY CLINIC OF WARREN PC
Entity type:Organization
Organization Name:ALLERGY CLINIC OF WARREN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:N
Authorized Official - Last Name:ZACKS
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:586-558-5700
Mailing Address - Street 1:28573 SCHOENHERR RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-4330
Mailing Address - Country:US
Mailing Address - Phone:586-558-5700
Mailing Address - Fax:586-558-9402
Practice Address - Street 1:28573 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-4330
Practice Address - Country:US
Practice Address - Phone:586-558-5700
Practice Address - Fax:586-558-9402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMZ035093207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0501676OtherBCBS
MI103944OtherPREFERRED CHOICES
MI103515OtherGREAT LAKES
MI1162941OtherHEALTH PLUS
MI1787391Medicaid
MI84180OtherTOTAL HEALTH
MI0501676OtherBLUE CARE NETWORK
MIB45174OtherHAP
MI1162941OtherHEALTH PLUS
MI0506294Medicare PIN