AZALEA ORTHOPEDIC & SPORTS MEDICINE CLINIC PA
Complete NPI Record 1699765107
Orthopaedic Surgery in Tyler, TX
Active since October 26, 2005
Complete NPI Dataset
This page contains the complete raw NPPES record for Azalea Orthopedic & Sports Medicine Clinic Pa (NPI 1699765107), an orthopaedic surgery organization in Tyler, TX. All 38 fields on file are listed with their current values and official NPPES definitions, exactly as recorded in the National Plan and Provider Enumeration System. Only fields that contain data are included, so the number of fields shown varies from one NPI record to another.
Use the tools below to filter fields by category, search within the record, or jump straight to a specific field. You can download the full record as a CSV, JSON, Markdown or text file, or filter first and export only the fields you need. The Print Clean Summary button produces a printer-friendly copy of the record.
Registry File Document Utilities
- NPI: 1699765107 Field 1/38
- The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
- Entity Type Code: 2 Field 2/38
- Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
- Employer Identification Number EIN: Not available Field 3/38
- The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
- Provider Organization Name Legal Business Name: AZALEA ORTHOPEDIC & SPORTS MEDICINE CLINIC PA Field 4/38
- The name of the organization provider. If the provider is an organization, this is the legal business name.
- Provider First Line Business Mailing Address: PO BOX 610307 Field 5/38
- The first line mailing address of the provider being identified. This data element may contain the same information as "Provider first line location address".
- Provider Business Mailing Address City Name: DALLAS Field 6/38
- The city name in the mailing address of the provider being identified.
- Provider Business Mailing Address State Name: TX Field 7/38
- The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address State name".
- Provider Business Mailing Address Postal Code: 752610307 Field 8/38
- The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as "Provider location address postal code".
- Provider Business Mailing Address Country Code If outside U S : US Field 9/38
- The country code in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address country code".
- Provider Business Mailing Address Telephone Number: 9039397500 Field 10/38
- The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as "Provider location address telephone number".
- Provider Business Mailing Address Fax Number: 9039397728 Field 11/38
- The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as "Provider location address fax number".
- Provider First Line Business Practice Location Address: 3414 GOLDEN ROAD Field 12/38
- The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
- Provider Business Practice Location Address City Name: TYLER Field 13/38
- The city name in the location address of the provider being identified.
- Provider Business Practice Location Address State Name: TX Field 14/38
- The State code in the location of the provider being identified.
- Provider Business Practice Location Address Postal Code: 75701 Field 15/38
- The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
- Provider Business Practice Location Address Country Code If outside U S : US Field 16/38
- The country code in the location address of the provider being identified.
- Provider Business Practice Location Address Telephone Number: 9039397500 Field 17/38
- The telephone number associated with the location address of the provider being identified.
- Provider Business Practice Location Address Fax Number: 9039397728 Field 18/38
- The fax number associated with the location address of the provider being identified.
- Authorized Official Last Name: EBERT Field 21/38
- The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
- Authorized Official First Name: HEIDI Field 22/38
- The first name of the authorized official.
- Authorized Official Title or Position: BILLING SUPERVISOR Field 23/38
- The title or position of the authorized official.
- Authorized Official Telephone Number: 9039397774 Field 24/38
- The 10-position telephone number of the authorized official.
- Healthcare Provider Taxonomy Code 1: 207X00000X Field 25/38
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Healthcare Provider Primary Taxonomy Switch 1: Y Field 26/38
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Healthcare Provider Taxonomy Code 2: 332B00000X Field 27/38
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Provider License Number 2: 0863040001 Field 28/38
- The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with "provider taxonomy code".
- Provider License Number State Code 2: TX Field 29/38
- The two-letter state code representing the U.S. state or territory that issued the provider's license. This field is linked to the Provider License Number field and identifies the jurisdiction where that license is valid. A provider may have multiple state codes if they hold licenses in more than one state.
- Healthcare Provider Primary Taxonomy Switch 2: N Field 30/38
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Other Provider Identifier 1: 084034002 Field 31/38
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 1: 05 Field 32/38
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 1: TX Field 33/38
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier 2: 084034001 Field 34/38
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 2: 05 Field 35/38
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 2: TX Field 36/38
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Is Organization Subpart: N Field 37/38
- Indicates whether the provider is a subpart of a larger organization. This is a single-character code: "Y" means the entity is an organizational subpart, while "N" means it is not. Subparts typically include hospital departments, clinics, or other distinct units that fall under a parent organization.
- Healthcare Provider Taxonomy Group 1: 193200000X MULTI-SPECIALTY GROUP Field 38/38
- Specifies whether the provider is part of a single-specialty or multi-specialty business group. The possible values are: 193200000X – Multi-Specialty Group or 193400000X – Single Specialty Group. This field helps distinguish the organizational structure of a provider group.
Secondary Practice Locations 9
The first line of the secondary practice location address of the provider being identified. For providers with more than one physical location, this is a secondary practice location address. This address cannot include a Post Office box.
1814 Roseland Blvd Ste 100
Location 1/9Tyler, TX 75701-4262 · Phone (903) 525-3300
8101 S Broadway Ave
Location 2/9Tyler, TX 75703-5469 · Phone (903) 939-7501
2211 S Loop 256
Location 3/9Palestine, TX 75801-4701 · Phone (903) 939-7500
2701 US Highway 271 N
Location 4/9Pittsburg, TX 75686-4289 · Phone (903) 946-5442
725 N 4th St
Location 5/9Longview, TX 75601-5412 · Phone (903) 939-7501
305 W 20th St
Location 6/9Mount Pleasant, TX 75455-2327 · Phone (903) 577-5661
4800 NE Stallings Dr Ste 110
Location 7/9Nacogdoches, TX 75965-1250 · Phone (903) 939-7500
6444 State Highway 19 S
Location 8/9Athens, TX 75751-8968 · Phone (903) 939-7501
203 Nacogdoches St Ste 350
Location 9/9Jacksonville, TX 75766-2454 · Phone (903) 939-7536
Other Provider Identifiers 2
Legacy and payer-issued identifiers reported to the NPPES registry for this provider.
084034002 Medicaid
Identifier 1/2State: TX
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
084034001 Medicaid
Identifier 2/2State: TX
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
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