Basic Information
Provider Information | |||||||||
NPI: | 1275115362 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WEDOWEE SPECIALTY CLINIC INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 706 DIXIE ST STE 220 | ||||||||
Address2: |   | ||||||||
City: | CARROLLTON | ||||||||
State: | GA | ||||||||
PostalCode: | 301173889 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708388710 | ||||||||
FaxNumber: | 7708125735 | ||||||||
Practice Location | |||||||||
Address1: | 1030 MAIN ST S STE 201 | ||||||||
Address2: |   | ||||||||
City: | WEDOWEE | ||||||||
State: | AL | ||||||||
PostalCode: | 362787440 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2563572188 | ||||||||
FaxNumber: | 2563572023 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/27/2021 | ||||||||
LastUpdateDate: | 04/27/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FOX | ||||||||
AuthorizedOfficialFirstName: | SUSAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SR. VP OF TMG OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 7708388302 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: | 04/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207RC0000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.