Provider Demographics
NPI:1154807337
Name:ALLERGY & IMMUNOLOGY ASSOCIATES OF DEARBORN PC
Entity type:Organization
Organization Name:ALLERGY & IMMUNOLOGY ASSOCIATES OF DEARBORN PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROULA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-623-7617
Mailing Address - Street 1:751 S MILITARY ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2107
Mailing Address - Country:US
Mailing Address - Phone:313-274-3311
Mailing Address - Fax:313-274-3311
Practice Address - Street 1:751 S MILITARY ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2107
Practice Address - Country:US
Practice Address - Phone:313-274-3311
Practice Address - Fax:313-274-3311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301101430207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8301701Medicaid