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General NPI Number Information
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NPI Number | 1699765107
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Entity Type | Organization
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Legal Business Name | AZALEA ORTHOPEDIC & SPORTS MEDICINE CLINIC PA
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Dates
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Enumeration Date | 10/26/2005
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Last Update Date | 01/28/2019
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Provider Practice Location Address
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Address Line | 3414 GOLDEN ROAD
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City | TYLER
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State | TX
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Zip | 75701
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Country | US
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Telephone | 903-939-7500
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Fax | 903-939-7728
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Provider Business Mailing Address
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Address Line | PO BOX 610307
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City | DALLAS
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State | TX
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Zip | 75261-0307
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Country | US
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Telephone | 903-939-7500
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Fax | 903-939-7728
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Authorized Official
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Title or Position | BILLING SUPERVISOR
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Name | HEIDI EBERT
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Credential |
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Telephone | 903-939-7774
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 0863040001
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number |
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License Number State |
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