Healthcare Provider Details

I. General information

NPI: 1730378738
Provider Name (Legal Business Name): ALLERGY ASSOCIATES OF DEARBORN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 S MILITARY ST
DEARBORN MI
48124-2107
US

IV. Provider business mailing address

751 S MILITARY ST
DEARBORN MI
48124-2107
US

V. Phone/Fax

Practice location:
  • Phone: 313-274-3311
  • Fax: 313-274-3587
Mailing address:
  • Phone: 313-274-3311
  • Fax: 313-274-3587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberJB047245
License Number StateMI

VIII. Authorized Official

Name: MRS. JANICE BERNICK
Title or Position: OFFICE MANAGER
Credential:
Phone: 313-274-3311