=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588670343
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLERGY & ASTHMA CARE OF INDIANA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2006
-----------------------------------------------------
Last Update Date | 07/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11590 N MERIDIAN ST STE 400
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46032-4599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-708-2839
-----------------------------------------------------
Fax | 317-708-2877
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11590 N MERIDIAN ST STE 400
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46032-4599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-708-2839
-----------------------------------------------------
Fax | 317-708-2877
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD PRESIDENT
-----------------------------------------------------
Name | GARRICK P HUBBARD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 317-708-2839
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 01042528
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------