MEDICARE: GROVER ASHTON WELLS III 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	23300	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51097094	OTHER	AL	BLUE CROSS BLUE SHIELD AL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	51094943	OTHER	AL	BLUE CROSS BLUE SHIELD AL

General Provider Information

NPI Number	:	1215974233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GROVER ASHTON WELLS III M.D.

Provider Business Mailing Address
First Line	:	PO BOX 158
Second Line	:
City	:	ANDALUSIA
State	:	AL
Zip	:	36420-1202
Country	:	US
Telephone Number	:	334-222-4191
Fax Number	:	334-222-9069

Provider Business Practice Location Address
First Line	:	125 MEDICAL PARK DR
Second Line	:	SUITE 106
City	:	ANDALUSIA
State	:	AL
Zip	:	36420-5316
Country	:	US
Telephone Number	:	334-222-4191
Fax Number	:	334-222-9069

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

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	05/20/2008

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