Provider Demographics
NPI:1104913417
Name:ALLERGY AND ASTHMA CENTER, INC
Entity type:Organization
Organization Name:ALLERGY AND ASTHMA CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIDYASHANKAR
Authorized Official - Middle Name:B
Authorized Official - Last Name:REVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-655-9179
Mailing Address - Street 1:110 FAIRWAY DR
Mailing Address - Street 2:SUITE # 2
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-8756
Mailing Address - Country:US
Mailing Address - Phone:937-655-9179
Mailing Address - Fax:937-655-9139
Practice Address - Street 1:110 FAIRWAY DR
Practice Address - Street 2:SUITE # 2
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-8756
Practice Address - Country:US
Practice Address - Phone:937-655-9179
Practice Address - Fax:937-655-9139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35080833207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2321660Medicaid
DD 2704OtherRAILROAD MEDICARE ID #
000000237118OtherBLUECROSS AND BLUESHIELD
0200482OtherUNITED HEALTH CARE
D80833OtherHUMANA / CHOICE CARE ID
0200482OtherUNITED HEALTH CARE
H60978Medicare UPIN