Healthcare Provider Details

I. General information

NPI: 1568449429
Provider Name (Legal Business Name): WIREGRASS RADIOLOGICAL CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 HOSPITAL AVE
OZARK AL
36360-2018
US

IV. Provider business mailing address

2015 ALEXANDER DR
DOTHAN AL
36301-3003
US

V. Phone/Fax

Practice location:
  • Phone: 334-671-1696
  • Fax: 334-794-0721
Mailing address:
  • Phone: 334-671-1696
  • Fax: 334-794-0721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateAL

VIII. Authorized Official

Name: DUDLEY J TERRELL
Title or Position: PRESIDENT
Credential: MD
Phone: 334-671-1696