Provider Demographics
NPI:1760512032
Name:AZALEA SKIN TREATMENT CENTER PA
Entity Type:Organization
Organization Name:AZALEA SKIN TREATMENT CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:KETCHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-773-4959
Mailing Address - Street 1:PO BOX 60634
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0634
Mailing Address - Country:US
Mailing Address - Phone:919-772-3487
Mailing Address - Fax:919-772-3446
Practice Address - Street 1:958 VANDORA SPRINGS RD
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-3544
Practice Address - Country:US
Practice Address - Phone:919-772-3487
Practice Address - Fax:919-772-3446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29605174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0273LOtherBCBS OF NC GROUP NUMBER
NC070014474OtherRAILROAD MEDICARE
NC2338206Medicare PIN