Healthcare Provider Details

I. General information

NPI: 1972811503
Provider Name (Legal Business Name): STATUS ALLERGY CLINIC OF KINGSPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 BRIDGEWATER DR.
KINGSPORT TN
37660
US

IV. Provider business mailing address

P.O. BOX 3490
KINGSPORT TN
37664
US

V. Phone/Fax

Practice location:
  • Phone: 423-247-1122
  • Fax: 423-247-3856
Mailing address:
  • Phone: 423-247-1122
  • Fax: 423-247-3856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMD0000015776
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD0000015776
License Number StateTN

VIII. Authorized Official

Name: NALINCHANDRA GOPALDAS SHAH
Title or Position: PRESIDENT - MD
Credential: MD
Phone: 423-247-1122