Healthcare Provider Details

I. General information

NPI: 1780648212
Provider Name (Legal Business Name): VAN RUSSELL WADLINGTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 12/22/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 CLARK ST NE
CULLMAN AL
35055-1921
US

IV. Provider business mailing address

503 CLARK ST NE
CULLMAN AL
35055-1921
US

V. Phone/Fax

Practice location:
  • Phone: 256-739-9898
  • Fax: 256-739-9556
Mailing address:
  • Phone: 256-739-0801
  • Fax: 256-739-0027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number18187
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number18187
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier009961805
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer
# 2
Identifier51521246
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerBLUE CROSS BLUE SHIELD
# 3
Identifier000046855
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer
# 4
Identifier51514426
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerBLUE CROSS/BLUE SHIELD
# 5
Identifier51550456
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerBLUE CROSS/BLUE SHIELD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: