Provider Demographics
NPI:1306118294
Name:MOUNTAINSIDE ALLERGY AND IMMUNOLOGY GROUP
Entity type:Organization
Organization Name:MOUNTAINSIDE ALLERGY AND IMMUNOLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-452-6222
Mailing Address - Street 1:PO BOX 19066
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-0066
Mailing Address - Country:US
Mailing Address - Phone:916-452-6222
Mailing Address - Fax:916-451-5534
Practice Address - Street 1:4801 J ST STE B
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3746
Practice Address - Country:US
Practice Address - Phone:916-452-6222
Practice Address - Fax:916-451-5534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GM857AOtherMEDICARE PTAN
DT7846OtherRAILROAD MEDICARE GROUP PTAN