Basic Information
| Provider Information | |||||||||
| NPI: | 1346817772 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WIREGRASS CLINIC LLC | ||||||||
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| OtherOrganizationName: | DOTHAN SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689022 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370689022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778929815 | ||||||||
| FaxNumber: | 6156286877 | ||||||||
| Practice Location | |||||||||
| Address1: | 1450 ROSS CLARK CIR STE 4 | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363014736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346997900 | ||||||||
| FaxNumber: | 3346997901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2021 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SR DIR PROV ENROLLMENT & ONBOARDING | ||||||||
| AuthorizedOfficialTelephone: | 6154653334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 003999940 | 05 | FL | MEDICAID |