Provider Demographics
NPI:1467664268
Name:AZALEA SURGERY CENTER
Entity Type:Organization
Organization Name:AZALEA SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGETT
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-259-0019
Mailing Address - Street 1:2810 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1716
Mailing Address - Country:US
Mailing Address - Phone:229-259-0019
Mailing Address - Fax:229-259-0209
Practice Address - Street 1:2810 NORTH OAK STREET
Practice Address - Street 2:
Practice Address - City:VALDSOTA
Practice Address - State:GA
Practice Address - Zip Code:31602
Practice Address - Country:US
Practice Address - Phone:229-259-0019
Practice Address - Fax:229-259-0209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA092266261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA598880OtherBCBS GA PROVIDER #
GAH01627Medicare UPIN
GA598880OtherBCBS GA PROVIDER #