Basic Information
| Provider Information | |||||||||
| NPI: | 1306808407 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLYMOUTH ASTHMA & ALLERGY CENTER PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9398 N LILLEY RD | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481704610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344592255 | ||||||||
| FaxNumber: | 7344591855 | ||||||||
| Practice Location | |||||||||
| Address1: | 9398 N LILLEY RD | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481704610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344592255 | ||||||||
| FaxNumber: | 7344591855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 05/26/2009 | ||||||||
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| AuthorizedOfficialLastName: | PEARL | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7344592255 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 5101004511 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 2628611 | 05 | MI | MEDICAID |