Provider Demographics
NPI:1982085197
Name:AZALEA NEURO AND SPINE CLINIC PC
Entity Type:Organization
Organization Name:AZALEA NEURO AND SPINE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HITHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KHALIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-469-7271
Mailing Address - Street 1:2109 N PATTERSON ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2990
Mailing Address - Country:US
Mailing Address - Phone:229-469-7271
Mailing Address - Fax:844-662-3122
Practice Address - Street 1:2109 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2990
Practice Address - Country:US
Practice Address - Phone:229-469-7271
Practice Address - Fax:844-662-3122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-12
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty