Provider Demographics
NPI:1316905342
Name:STANLEY A. WADE, JR., MD, PLLC
Entity type:Organization
Organization Name:STANLEY A. WADE, JR., MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WADE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:205-459-4778
Mailing Address - Street 1:PO BOX 328
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-0328
Mailing Address - Country:US
Mailing Address - Phone:601-703-9506
Mailing Address - Fax:601-703-3264
Practice Address - Street 1:1800 12TH ST
Practice Address - Street 2:SUITE 3A
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4158
Practice Address - Country:US
Practice Address - Phone:601-703-9223
Practice Address - Fax:601-703-9405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DA7320OtherRAILROAD MEDICARE
MS06874076Medicaid
=========OtherTRICARE
MS06874076Medicaid