Basic Information
| Provider Information | |||||||||
| NPI: | 1780648212 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WADLINGTON | ||||||||
| FirstName: | VAN | ||||||||
| MiddleName: | RUSSELL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 503 CLARK ST NE | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350551921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567390801 | ||||||||
| FaxNumber: | 2567390027 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 CLARK ST NE | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350551921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567399898 | ||||||||
| FaxNumber: | 2567399556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 12/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 18187 | AL | N | Allopathic & Osteopathic Physicians | General Practice | 2085R0202X | 18187 | AL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 009961805 | 05 | AL | MEDICAID | 51521246 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | 000046855 | 05 | AL | MEDICAID | 51514426 | 01 | AL | BLUE CROSS/BLUE SHIELD | OTHER | 51550456 | 01 | AL | BLUE CROSS/BLUE SHIELD | OTHER |