=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225448921
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE PALM BEACH CENTER FOR FACIAL PLASTIC & LASER SURGERY, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2014
-----------------------------------------------------
Last Update Date | 08/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4495 MILITARY TRL STE 202
-----------------------------------------------------
City | JUPITER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-429-5403
-----------------------------------------------------
Fax | 561-626-6277
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4495 MILITARY TRL SUITE 202
-----------------------------------------------------
City | JUPITER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33458-4839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JEAN PAUL AZZI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 561-429-5403
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207YX0007X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery within the Head & Neck (Otolaryngology) Physician
-----------------------------------------------------
License Number | ME134770
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207YS0123X
-----------------------------------------------------
Taxonomy Name | Facial Plastic Surgery Physician
-----------------------------------------------------
License Number | ME117560
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------