Healthcare Provider Details

I. General information

NPI: 1477545200
Provider Name (Legal Business Name): DEARBORN ALLERGY & ASTHMA CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20200 OUTER DR
DEARBORN MI
48124-2634
US

IV. Provider business mailing address

20200 OUTER DR
DEARBORN MI
48124-2634
US

V. Phone/Fax

Practice location:
  • Phone: 313-565-3565
  • Fax: 313-565-7723
Mailing address:
  • Phone: 313-565-3565
  • Fax: 313-565-7723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. KATHY SHORT
Title or Position: OFFICE MANAGER
Credential:
Phone: 313-565-3565