Organization
AZALEA CENTER FOR PLASTIC SURGERY PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BRIDGETT MOORE MD (MEDICAL DIRECTOR)
(229) 259-0019
Entity
Organization
Contact information
Practice address
2810 N OAK ST, VALDOSTA, GA 31602-1716
(229) 259-0019
(229) 259-0209
Mailing address
2810 N OAK ST, VALDOSTA, GA 31602-1716
(229) 259-0019
(229) 259-0209
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
39418
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00830277A
—
GA
01
—
110206439
MEDICARE RR PROVIDER #
GA
01
—
511G700695
MEDICARE GROUP PIN
GA
01
—
598880
BCBS GA PROVIDER #
GA
Enumeration date
03/06/2007
Last updated
02/06/2014
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