Provider Demographics
NPI:1306808407
Name:PLYMOUTH ASTHMA & ALLERGY CENTER PC
Entity type:Organization
Organization Name:PLYMOUTH ASTHMA & ALLERGY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:W
Authorized Official - Last Name:PEARL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-459-2255
Mailing Address - Street 1:9398 N LILLEY RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4610
Mailing Address - Country:US
Mailing Address - Phone:734-459-2255
Mailing Address - Fax:734-459-1855
Practice Address - Street 1:9398 N LILLEY RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4610
Practice Address - Country:US
Practice Address - Phone:734-459-2255
Practice Address - Fax:734-459-1855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101004511207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2628611Medicaid
E21645Medicare UPIN
MI2628611Medicaid