Basic Information
| Provider Information | |||||||||
| NPI: | 1588779482 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF COAST ALLERGY CENTER PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 494507 | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339494507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417432277 | ||||||||
| FaxNumber: | 9417432275 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 TAMIAMI TRL | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339528102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417432277 | ||||||||
| FaxNumber: | 9417432275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 10/22/2007 | ||||||||
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| AuthorizedOfficialLastName: | CHANDRAHASA | ||||||||
| AuthorizedOfficialFirstName: | USHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9417432277 | ||||||||
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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 | ME84695 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 17055 | 01 | FL | BCBS FL | OTHER |