Provider Demographics
NPI:1255486452
Name:WALLACE, EDWARD ALTON (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ALTON
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3100 SPRING FOREST RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2880
Mailing Address - Country:US
Mailing Address - Phone:919-882-0705
Mailing Address - Fax:919-873-9821
Practice Address - Street 1:300 SINGLETON RIDGE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9142
Practice Address - Country:US
Practice Address - Phone:843-669-5162
Practice Address - Fax:843-669-5162
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13597207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900433Medicaid
SC135972Medicaid
SC570835798OtherSTANDARD TAX ID
SCE0051OtherMEDCOST
SC570835798OtherSTANDARD TAX ID
SCP00194500Medicare ID - Type UnspecifiedRAILROAD MEDICARE
SCE0051OtherMEDCOST
NC5900433Medicaid
SCD790695798Medicare Oscar/Certification