Provider Demographics
NPI:1871620484
Name:WIREGRASS RADIATION ONCOLOGY PC
Entity type:Organization
Organization Name:WIREGRASS RADIATION ONCOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARROD
Authorized Official - Middle Name:B
Authorized Official - Last Name:ADKISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-699-8111
Mailing Address - Street 1:PO BOX 11407
Mailing Address - Street 2:DEPT. 2131
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-2131
Mailing Address - Country:US
Mailing Address - Phone:334-793-8081
Mailing Address - Fax:334-793-1448
Practice Address - Street 1:1108 ROSS CLARK CIR
Practice Address - Street 2:RADIATION ONCOLOGY
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3022
Practice Address - Country:US
Practice Address - Phone:334-793-8081
Practice Address - Fax:334-793-1448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-98066OtherBCBS DOTHAN
AL529917150Medicaid
DC5678OtherRAILROAD MEDICARE
AL=========OtherTRICARE
DC5678OtherRAILROAD MEDICARE
DC5678OtherRAILROAD MEDICARE
DC5678OtherRAILROAD MEDICARE