Provider Demographics
NPI:1750386942
Name:HOLMAN, WILTON RUSSELL III (MD)
Entity type:Individual
Prefix:
First Name:WILTON
Middle Name:RUSSELL
Last Name:HOLMAN
Suffix:III
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 1:2000A SOUTHBRIDGE PKWY
Mailing Address - Street 2:STE 300
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-7718
Mailing Address - Country:US
Mailing Address - Phone:205-871-4274
Mailing Address - Fax:205-871-4301
Practice Address - Street 1:701 PRINCETON AVE SW
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-1303
Practice Address - Country:US
Practice Address - Phone:205-783-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL205442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL122606Medicaid
AL515-39411OtherBLUE CROSS
AL300113603OtherRRMC
AL515-94523OtherBLUE CROSS
AL511-56374OtherBLUE CROSS
AL7575354OtherAETNA
AL511-09727OtherBLUE CROSS
AL000055398Medicaid
AL105489Medicaid
AL169815Medicaid
AL510-55398OtherBLUE CROSS
AL009941749Medicaid
AL000055398Medicare PIN
AL7575354OtherAETNA
AL102I309195Medicare PIN