Provider Demographics
NPI:1780648212
Name:WADLINGTON, VAN RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:VAN
Middle Name:RUSSELL
Last Name:WADLINGTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 CLARK ST NE
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-1921
Mailing Address - Country:US
Mailing Address - Phone:256-739-0801
Mailing Address - Fax:256-739-0027
Practice Address - Street 1:501 CLARK ST NE
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-1921
Practice Address - Country:US
Practice Address - Phone:256-739-9898
Practice Address - Fax:256-739-9556
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL18187208D00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009961805Medicaid
AL51521246OtherBLUE CROSS BLUE SHIELD
AL000046855Medicaid
AL51514426OtherBLUE CROSS/BLUE SHIELD
AL51550456OtherBLUE CROSS/BLUE SHIELD
ALP00125865Medicare ID - Type UnspecifiedRAILROAD MEDICARE
AL51550456OtherBLUE CROSS/BLUE SHIELD
ALF64791Medicare UPIN
AL051550456Medicare ID - Type Unspecified
AL000046855Medicaid
AL300122669Medicare PIN