MEDICARE: DR. KENDALL CHARLES VAGUE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	9565	AL
2	207X00000X	Orthopaedic Surgery Physician	9565	AL

General Provider Information

NPI Number	:	1114925237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENDALL CHARLES VAGUE M.D.

Provider Business Mailing Address
First Line	:	2950 HIGHWAY 78 E
Second Line	:
City	:	JASPER
State	:	AL
Zip	:	35501-8903
Country	:	US
Telephone Number	:	205-221-5374
Fax Number	:	205-384-1453

Provider Business Practice Location Address
First Line	:	2950 HIGHWAY 78 E
Second Line	:
City	:	JASPER
State	:	AL
Zip	:	35501-8903
Country	:	US
Telephone Number	:	205-221-5374
Fax Number	:	205-384-1453

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	02/10/2021

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