1568449429 NPI number — WIREGRASS RADIOLOGICAL CONSULTANTS

Table of content: (NPI 1568449429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568449429 NPI number — WIREGRASS RADIOLOGICAL CONSULTANTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WIREGRASS RADIOLOGICAL CONSULTANTS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568449429
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2015 ALEXANDER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36301-3003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-671-1696
Provider Business Mailing Address Fax Number:
334-794-0721

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
126 HOSPITAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OZARK
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36360-2018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-671-1696
Provider Business Practice Location Address Fax Number:
334-794-0721
Provider Enumeration Date:
12/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TERRELL
Authorized Official First Name:
DUDLEY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
334-671-1696

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 528301670 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com