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General NPI Number Information
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NPI Number | 1770863276
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Entity Type | Organization
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Legal Business Name | ALLERGY & IMMUNOLOGY CENTER PC
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Dates
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Enumeration Date | 08/29/2011
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Last Update Date | 03/20/2013
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Provider Practice Location Address
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Address Line | 1911 PALMYRA RD
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City | ALBANY
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State | GA
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Zip | 31701-1574
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Country | US
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Telephone | 229-446-7227
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Fax | 229-420-4365
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Provider Business Mailing Address
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Address Line | 1911 PALMYRA RD
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City | ALBANY
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State | GA
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Zip | 31701-1574
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Country | US
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Telephone | 229-446-7227
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Fax | 229-420-4365
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | JOSE THECKEDATH
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Credential | MD
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Telephone | 229-446-7227
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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 | 045992
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License Number State | GA
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