Provider Demographics
NPI:1740383983
Name:AZALEA OB/GYN, PC
Entity type:Organization
Organization Name:AZALEA OB/GYN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAPHNE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-331-3988
Mailing Address - Street 1:523 GANDY ST NE
Mailing Address - Street 2:SUITE F
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-1961
Mailing Address - Country:US
Mailing Address - Phone:256-331-3988
Mailing Address - Fax:256-331-3987
Practice Address - Street 1:523 GANDY ST NE
Practice Address - Street 2:SUITE F
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-1961
Practice Address - Country:US
Practice Address - Phone:256-331-3988
Practice Address - Fax:256-331-3987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00027647207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALG89693Medicare UPIN