Basic Information
| Provider Information | |||||||||
| NPI: | 1316013295 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WV ASTHMA & ALLERGY CENTERS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ASTHMA & ALLERGY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 208 MACCORKLE AVE SE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253141160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043434300 | ||||||||
| FaxNumber: | 3043435472 | ||||||||
| Practice Location | |||||||||
| Address1: | 208 MACCORKLE AVE SE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253141160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043434300 | ||||||||
| FaxNumber: | 3043435472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2006 | ||||||||
| LastUpdateDate: | 07/02/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KUMAR | ||||||||
| AuthorizedOfficialFirstName: | CHANDRA | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3043434300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 11875 | WV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 38100000011102 | 05 | WV | MEDICAID | 3810011107 | 05 | WV | MEDICAID | 3810000783 | 05 | WV | MEDICAID | 3810011109 | 05 | WV | MEDICAID | 3810025797 | 05 | WV | MEDICAID | 3810011961 | 05 | WV | MEDICAID |