Provider Demographics
NPI:1972811503
Name:STATUS ALLERGY CLINIC OF KINGSPORT
Entity type:Organization
Organization Name:STATUS ALLERGY CLINIC OF KINGSPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT - MD
Authorized Official - Prefix:
Authorized Official - First Name:NALINCHANDRA
Authorized Official - Middle Name:GOPALDAS
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-247-1122
Mailing Address - Street 1:P.O. BOX 3490
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664
Mailing Address - Country:US
Mailing Address - Phone:423-247-1122
Mailing Address - Fax:423-247-3856
Practice Address - Street 1:1516 BRIDGEWATER DR.
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660
Practice Address - Country:US
Practice Address - Phone:423-247-1122
Practice Address - Fax:423-247-3856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000015776207K00000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64663172Medicaid
KY64663172Medicaid
TN3079726Medicare PIN