Provider Demographics
NPI:1053577536
Name:ADVANCED ASTHMA ALLERGY & IMMUNOLOGY CARE PC
Entity type:Organization
Organization Name:ADVANCED ASTHMA ALLERGY & IMMUNOLOGY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:STRINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-969-8920
Mailing Address - Street 1:49 S CASS ST
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49037-2331
Mailing Address - Country:US
Mailing Address - Phone:269-969-8920
Mailing Address - Fax:269-969-8921
Practice Address - Street 1:4870 W CLARK RD
Practice Address - Street 2:SUITE 202
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1104
Practice Address - Country:US
Practice Address - Phone:734-434-5430
Practice Address - Fax:734-434-5762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICC788218207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104929015Medicaid