=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093720740
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASTHMA, ALLERGY AND SINUS CENTER, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 115 N DELAWARE ST
-----------------------------------------------------
City | SANDUSKY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48471-1008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-648-4544
-----------------------------------------------------
Fax | 810-648-5924
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1108 ATTN: LYNDA THOMPSON
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48106-1108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-677-7400
-----------------------------------------------------
Fax | 734-677-7407
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MUTEE ABDELJABER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 810-648-4544
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207KA0200X
-----------------------------------------------------
Taxonomy Name | Allergy Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------