Healthcare Provider Details

I. General information

NPI: 1922094085
Provider Name (Legal Business Name): LARRY WAYNE WADE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2619 DECATUR HWY
FULTONDALE AL
35068-1723
US

IV. Provider business mailing address

2619 DECATUR HWY
FULTONDALE AL
35068-1723
US

V. Phone/Fax

Practice location:
  • Phone: 205-841-9898
  • Fax: 205-841-9880
Mailing address:
  • Phone: 205-841-9898
  • Fax: 205-841-9880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number00017461
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: