Basic Information
| Provider Information | |||||||||
| NPI: | 1891718151 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDIC & SPORTSMEDICINE SPECIALISTS OF CULLMAN PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1938 AL HIGHWAY 157 | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350580609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567394030 | ||||||||
| FaxNumber: | 2567395743 | ||||||||
| Practice Location | |||||||||
| Address1: | 1938 AL HIGHWAY 157 | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350580609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567394030 | ||||||||
| FaxNumber: | 2567395743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 04/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | BERGQUIST | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2567394030 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 14798 | AL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 213E00000X | 191 | AL | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | 173 | AL | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 207RS0010X | 00027474 | AL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine | 207X00000X | 6543 | AL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 528300730 | 05 | AL | MEDICAID |