Provider Demographics
NPI:1912107962
Name:NORTHSHORE ALLERGY & IMMUNOLOGY, LLC
Entity type:Organization
Organization Name:NORTHSHORE ALLERGY & IMMUNOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GUILLOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-792-4022
Mailing Address - Street 1:804 HEAVENS DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-2890
Mailing Address - Country:US
Mailing Address - Phone:985-792-4022
Mailing Address - Fax:985-792-4007
Practice Address - Street 1:804 HEAVENS DR
Practice Address - Street 2:SUITE 203
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-2890
Practice Address - Country:US
Practice Address - Phone:985-792-4022
Practice Address - Fax:985-792-4007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD-020599207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1905445Medicaid
LAE57308Medicare UPIN
LA5N261Medicare PIN