Healthcare Provider Details

I. General information

NPI: 1306808407
Provider Name (Legal Business Name): PLYMOUTH ASTHMA & ALLERGY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 05/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9398 N LILLEY RD
PLYMOUTH MI
48170-4610
US

IV. Provider business mailing address

9398 N LILLEY RD
PLYMOUTH MI
48170-4610
US

V. Phone/Fax

Practice location:
  • Phone: 734-459-2255
  • Fax: 734-459-1855
Mailing address:
  • Phone: 734-459-2255
  • Fax: 734-459-1855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number5101004511
License Number StateMI

VIII. Authorized Official

Name: DR. JACK W PEARL
Title or Position: PRESIDENT
Credential: DO
Phone: 734-459-2255