Provider Demographics
NPI:1104035526
Name:WALLACE, AMBER ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:AMBER
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:
Other - Last Name:MORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:1686 SKYLYN DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307
Practice Address - Country:US
Practice Address - Phone:864-560-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-01577207V00000X
SCMD35398207V00000X
IN01063765A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC07926162OtherMEDICARE PIN
SCP01330093OtherRAILROAD MEDICARE
SCNC1735Medicaid
SCSC07923365OtherMEDICARE PIN