Basic Information
Provider Information | |||||||||
NPI: | 1255653192 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALLERGY CLINIC,P.A. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 311 E MONROE AVE | ||||||||
Address2: |   | ||||||||
City: | JONESBORO | ||||||||
State: | AR | ||||||||
PostalCode: | 724012923 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8709721667 | ||||||||
FaxNumber: | 8709720466 | ||||||||
Practice Location | |||||||||
Address1: | 311 E MONROE AVE | ||||||||
Address2: |   | ||||||||
City: | JONESBORO | ||||||||
State: | AR | ||||||||
PostalCode: | 724012923 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8709721667 | ||||||||
FaxNumber: | 8709720466 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/19/2010 | ||||||||
LastUpdateDate: | 02/19/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SNODGRASS | ||||||||
AuthorizedOfficialFirstName: | SCOT | ||||||||
AuthorizedOfficialMiddleName: | J. | ||||||||
AuthorizedOfficialTitleorPosition: | PHYISICAN | ||||||||
AuthorizedOfficialTelephone: | 8709721667 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy |
ID Information
ID | Type | State | Issuer | Description | 116452001 | 05 | AR |   | MEDICAID | 53369 | 01 | AR | BCBS | OTHER |