Provider Demographics
NPI:1164610580
Name:BC WALL MEDICAL GROUP PA
Entity Type:Organization
Organization Name:BC WALL MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:704-866-4607
Mailing Address - Street 1:557 CAMERON POINTE LN
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28012-6702
Mailing Address - Country:US
Mailing Address - Phone:704-825-2363
Mailing Address - Fax:704-825-2363
Practice Address - Street 1:1574 UNION ROAD
Practice Address - Street 2:A
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5633
Practice Address - Country:US
Practice Address - Phone:704-866-4607
Practice Address - Fax:704-866-5292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701190207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891057PMedicaid
NCG20887Medicare UPIN
NC891057PMedicaid