Provider Demographics
NPI:1699765107
Name:AZALEA ORTHOPEDIC & SPORTS MEDICINE CLINIC PA
Entity type:Organization
Organization Name:AZALEA ORTHOPEDIC & SPORTS MEDICINE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:EBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-939-7774
Mailing Address - Street 1:PO BOX 610307
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75261-0307
Mailing Address - Country:US
Mailing Address - Phone:903-939-7500
Mailing Address - Fax:903-939-7728
Practice Address - Street 1:3414 GOLDEN ROAD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701
Practice Address - Country:US
Practice Address - Phone:903-939-7500
Practice Address - Fax:903-939-7728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X
TX0863040001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX084034001Medicaid
TX084034002Medicaid
TX084034001Medicaid
TX00N01AMedicare PIN