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General NPI Number Information
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NPI Number | 1104913417
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Entity Type | Organization
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Legal Business Name | ALLERGY AND ASTHMA CENTER, INC
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Dates
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Enumeration Date | 10/06/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 110 FAIRWAY DR SUITE # 2
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City | WILMINGTON
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State | OH
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Zip | 45177-8756
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Country | US
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Telephone | 937-655-9179
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Fax | 937-655-9139
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Provider Business Mailing Address
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Address Line | 110 FAIRWAY DR SUITE # 2
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City | WILMINGTON
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State | OH
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Zip | 45177-8756
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Country | US
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Telephone | 937-655-9179
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Fax | 937-655-9139
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Authorized Official
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Title or Position | MD / PRESIDENT
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Name | DR. VIDYASHANKAR B REVAN
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Credential | M.D.
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Telephone | 937-655-9179
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | 35080833
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License Number State | OH
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