Provider Demographics
NPI:1457898983
Name:WIREGRASS MEDICAL ASSOCIATES 2 LLC
Entity type:Organization
Organization Name:WIREGRASS MEDICAL ASSOCIATES 2 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:W
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-699-5780
Mailing Address - Street 1:2431 W MAIN ST
Mailing Address - Street 2:STE 1102
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1217
Mailing Address - Country:US
Mailing Address - Phone:334-699-5780
Mailing Address - Fax:334-699-5786
Practice Address - Street 1:2431 W MAIN ST
Practice Address - Street 2:STE 1102
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1217
Practice Address - Country:US
Practice Address - Phone:334-699-5780
Practice Address - Fax:334-699-5786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty