Basic Information
| Provider Information | |||||||||
| NPI: | 1073568747 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AZZARELLO | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX BOX 864074 | ||||||||
| Address2: | HALIFAX HEALTHCARE SYSTEMS, INC. | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328864074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862264590 | ||||||||
| FaxNumber: | 3862263371 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 NO. CLYDE MORRIS BLVD. | ||||||||
| Address2: | HALIFAX MEDICAL CENTER - CHEST PAIN CENTER | ||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321142709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864251800 | ||||||||
| FaxNumber: | 3864251804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 10/26/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9103151 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 292228200 | 05 | FL | MEDICAID |