Healthcare Provider Details

I. General information

NPI: 1659329753
Provider Name (Legal Business Name): ROBERT STEPHEN WADE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 MORNINGSIDE DR SUITE A
PERRY GA
31069-4948
US

IV. Provider business mailing address

233 N HOUSTON RD SUITE 140-H
WARNER ROBINS GA
31093-3074
US

V. Phone/Fax

Practice location:
  • Phone: 478-988-2205
  • Fax: 478-988-2201
Mailing address:
  • Phone: 478-923-3360
  • Fax: 478-923-9977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number031350
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: