=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942629589
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AZALEA MEDICAL, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2014
-----------------------------------------------------
Last Update Date | 02/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3305 METAIRIE RD. STE. 1
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-434-2330
-----------------------------------------------------
Fax | 504-885-0820
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3305 METAIRIE RD. STE. 1
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-434-2330
-----------------------------------------------------
Fax | 504-885-0820
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KATHARINE J. ROSE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 504-434-2330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251T00000X
-----------------------------------------------------
Taxonomy Name | PACE Provider Organization
-----------------------------------------------------
License Number | 201310
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 201310
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------