Provider Demographics
NPI:1346359205
Name:WALLACE, RODGER T (MD)
Entity Type:Individual
Prefix:DR
First Name:RODGER
Middle Name:T
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:341 WALLACE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-8000
Mailing Address - Country:US
Mailing Address - Phone:615-834-7744
Mailing Address - Fax:615-834-7786
Practice Address - Street 1:341 WALLACE RD
Practice Address - Street 2:SUITE A
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211-8000
Practice Address - Country:US
Practice Address - Phone:615-834-7744
Practice Address - Fax:615-834-7786
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD6949207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3419805Medicaid
TNB02264Medicare UPIN
TN3149805Medicare ID - Type Unspecified