Provider Demographics
NPI:1750387833
Name:WIREGRASS SURGICAL ASSOCIATES, P.C.
Entity type:Organization
Organization Name:WIREGRASS SURGICAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:FENDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-793-1534
Mailing Address - Street 1:1118 ROSS CLARK CIR
Mailing Address - Street 2:STE 310
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3002
Mailing Address - Country:US
Mailing Address - Phone:334-793-1534
Mailing Address - Fax:334-793-6991
Practice Address - Street 1:1118 ROSS CLARK CIR
Practice Address - Street 2:STE 310
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3002
Practice Address - Country:US
Practice Address - Phone:334-793-1534
Practice Address - Fax:334-793-6991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0074230208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Not Answered2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000003047248OtherPHCS GROUP ID #
AL000003047248OtherPHCS GROUP ID #
=========002OtherCHAMPUS GROUP #