Healthcare Provider Details

I. General information

NPI: 1891718151
Provider Name (Legal Business Name): ORTHOPEDIC & SPORTSMEDICINE SPECIALISTS OF CULLMAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1938 AL HIGHWAY 157 SUITE 101
CULLMAN AL
35058-0609
US

IV. Provider business mailing address

1938 AL HIGHWAY 157 SUITE 101
CULLMAN AL
35058-0609
US

V. Phone/Fax

Practice location:
  • Phone: 256-739-4030
  • Fax: 256-739-5743
Mailing address:
  • Phone: 256-739-4030
  • Fax: 256-739-5743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number00027474
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number6543
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number14798
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number191
License Number StateAL
# 5
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number173
License Number StateAL

VIII. Authorized Official

Name: DR. VINCENT F BERGQUIST JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 256-739-4030