Healthcare Provider Details

I. General information

NPI: 1518902022
Provider Name (Legal Business Name): ALLERGY & ASTHMA CARE OF W MI PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 05/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 EAST PARIS SE SUITE 150
GRAND RAPIDS MI
49546-3680
US

IV. Provider business mailing address

1179 EAST PARIS SE SUITE 150
GRAND RAPIDS MI
49546-3680
US

V. Phone/Fax

Practice location:
  • Phone: 616-957-1912
  • Fax: 616-957-0074
Mailing address:
  • Phone: 616-957-1912
  • Fax: 616-957-0074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number4301071401
License Number StateMI

VIII. Authorized Official

Name: MARK M MILLAR
Title or Position: PRESIDENT
Credential: MD
Phone: 616-957-1912