Basic Information
| Provider Information | |||||||||
| NPI: | 1790045409 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN A AZZATO MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11505 | ||||||||
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| City: | SOUTHPORT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284611505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108055578 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1513 N HOWE ST | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | SOUTHPORT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284612769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108055578 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2012 | ||||||||
| LastUpdateDate: | 01/16/2013 | ||||||||
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| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9108055578 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 202C00000X | 20698 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Independent Medical Examiner | 207X00000X | 20698 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8912440 | 05 | NC | MEDICAID |