Provider Demographics
NPI:1952431223
Name:AZALEA CENTER FOR PLASTIC SURGERY PC
Entity Type:Organization
Organization Name:AZALEA CENTER FOR PLASTIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
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 N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1716
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:2007-03-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA39418174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA110206439OtherMEDICARE RR PROVIDER #
GA598880OtherBCBS GA PROVIDER #
GA00830277AMedicaid
GA511G700695OtherMEDICARE GROUP PIN
GA24BCBRCMedicare PIN
GA00830277AMedicaid