Provider Demographics
NPI:1922094085
Name:WADE, LARRY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:WAYNE
Last Name:WADE
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 1:2619 DECATUR HWY
Mailing Address - Street 2:
Mailing Address - City:FULTONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35068-1723
Mailing Address - Country:US
Mailing Address - Phone:205-841-9898
Mailing Address - Fax:205-841-9880
Practice Address - Street 1:2619 DECATUR HWY
Practice Address - Street 2:
Practice Address - City:FULTONDALE
Practice Address - State:AL
Practice Address - Zip Code:35068-1723
Practice Address - Country:US
Practice Address - Phone:205-841-9898
Practice Address - Fax:205-841-9880
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00017461207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051503805Medicaid
AL0051503805Medicare NSC
ALI635Medicare PIN
AL051503805Medicaid