Provider Demographics
NPI:1710194097
Name:AZALEA WOMENS CENTER, PC
Entity Type:Organization
Organization Name:AZALEA WOMENS CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SHARON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-242-8888
Mailing Address - Street 1:2307 N PATTERSON ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2510
Mailing Address - Country:US
Mailing Address - Phone:229-242-8888
Mailing Address - Fax:229-242-0069
Practice Address - Street 1:2307 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2510
Practice Address - Country:US
Practice Address - Phone:229-242-8888
Practice Address - Fax:229-242-0069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040845174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300035443AMedicaid
GA3948OtherGROUP NUMBER
GA300035443AMedicaid