Provider Demographics
NPI:1568449429
Name:WIREGRASS RADIOLOGICAL CONSULTANTS
Entity Type:Organization
Organization Name:WIREGRASS RADIOLOGICAL CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DUDLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:TERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-671-1696
Mailing Address - Street 1:2015 ALEXANDER DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3003
Mailing Address - Country:US
Mailing Address - Phone:334-671-1696
Mailing Address - Fax:334-794-0721
Practice Address - Street 1:126 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-2018
Practice Address - Country:US
Practice Address - Phone:334-671-1696
Practice Address - Fax:334-794-0721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL528301670Medicaid
ALH070Medicare PIN
AL528301670Medicaid