Provider Demographics
NPI:1225005069
Name:WALLACE, SIDNEY L (MD)
Entity Type:Individual
Prefix:DR
First Name:SIDNEY
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 FORT SANDERS WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3355
Mailing Address - Country:US
Mailing Address - Phone:865-769-4545
Mailing Address - Fax:865-769-4501
Practice Address - Street 1:260 FORT SANDERS WEST BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3355
Practice Address - Country:US
Practice Address - Phone:865-558-4400
Practice Address - Fax:865-769-4536
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD747207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN200030085OtherRAILROAD MEDICARE
TN3122938Medicaid
TN4465401OtherAETNA
TNTN0124OtherJOHN DEERE HEALTHCARE
TN100011199OtherTENNCARE
TN1201443OtherUNITED HEALTH CARE
TNTN0153OtherJOHN DEERE HEALTHCARE
TN3071355OtherBLUE CROSS BLUE SHIELD
TN1201443OtherUNITED HEALTH CARE
B59150Medicare UPIN
TN103I201394Medicare PIN
3122936Medicare ID - Type Unspecified
TN200030085OtherRAILROAD MEDICARE