Basic Information
| Provider Information | |||||||||
| NPI: | 1104913417 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALLERGY AND ASTHMA CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 FAIRWAY DR | ||||||||
| Address2: | SUITE # 2 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451778756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376559179 | ||||||||
| FaxNumber: | 9376559139 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 FAIRWAY DR | ||||||||
| Address2: | SUITE # 2 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451778756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376559179 | ||||||||
| FaxNumber: | 9376559139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | REVAN | ||||||||
| AuthorizedOfficialFirstName: | VIDYASHANKAR | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | MD / PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9376559179 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 35080833 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 2321660 | 05 | OH | MEDICAID | DD 2704 | 01 | RAILROAD MEDICARE ID # | OTHER | 000000237118 | 01 | BLUECROSS AND BLUESHIELD | OTHER | 0200482 | 01 | UNITED HEALTH CARE | OTHER | D80833 | 01 | HUMANA / CHOICE CARE ID | OTHER |