Organization
AZALEA SKIN TREATMENT CENTER PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. WILLIAM STEWART KETCHAM M.D. (PRESIDENT)
(919) 773-4959
Entity
Organization
Contact information
Practice address
958 VANDORA SPRINGS RD, GARNER, NC 27529-3544
(919) 772-3487
(919) 772-3446
Mailing address
PO BOX 60634, CHARLOTTE, NC 28260-0634
(919) 772-3487
(919) 772-3446
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
29605
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0273L
BCBS OF NC GROUP NUMBER
NC
01
—
070014474
RAILROAD MEDICARE
NC
Enumeration date
03/06/2007
Last updated
04/26/2012
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