Provider Demographics
NPI:1235238635
Name:WIREGRASS FAMILY PRACTICE OF DOTHAN PC
Entity Type:Organization
Organization Name:WIREGRASS FAMILY PRACTICE OF DOTHAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MIMS
Authorized Official - Middle Name:
Authorized Official - Last Name:HACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:334-699-8585
Mailing Address - Street 1:1836 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1320
Mailing Address - Country:US
Mailing Address - Phone:334-699-8585
Mailing Address - Fax:334-699-8587
Practice Address - Street 1:1836 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1320
Practice Address - Country:US
Practice Address - Phone:334-699-8585
Practice Address - Fax:334-699-8587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51530696OtherBCBS
AL51530696OtherBCBS