Healthcare Provider Details

I. General information

NPI: 1336128545
Provider Name (Legal Business Name): RONNIE D WIGGINS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4370 W MAIN ST ANESTHESIA DEPT
DOTHAN AL
36305-1056
US

IV. Provider business mailing address

PO BOX 934399
ATLANTA GA
31193-4399
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-5000
  • Fax: 334-615-7281
Mailing address:
  • Phone: 770-232-8611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number19429
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD 19429
License Number StateAL

VII. Legacy identifiers

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

# 1
Identifier100679
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer
# 2
Identifier051548708
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerBCBS
# 3
Identifier605331107A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 4
IdentifierPENDING
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: