1750387833 NPI number — WIREGRASS SURGICAL ASSOCIATES, P.C.

Table of content: (NPI 1750387833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750387833 NPI number — WIREGRASS SURGICAL ASSOCIATES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WIREGRASS SURGICAL ASSOCIATES, P.C.
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:
1750387833
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1118 ROSS CLARK CIR
Provider Second Line Business Mailing Address:
STE 310
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36301-3002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-793-1534
Provider Business Mailing Address Fax Number:
334-793-6991

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1118 ROSS CLARK CIR
Provider Second Line Business Practice Location Address:
STE 310
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36301-3002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-793-1534
Provider Business Practice Location Address Fax Number:
334-793-6991
Provider Enumeration Date:
06/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FENDLEY
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
334-793-1534

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  0074230 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2086S0129X , with the licence number: 0074230 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 000003047248 . This is a "PHCS GROUP ID #" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 102329100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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