Provider Demographics
NPI:1386627040
Name:WALL, ROBERT T JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:T
Last Name:WALL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:9330 MEDICAL PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9104
Mailing Address - Country:US
Mailing Address - Phone:843-847-3225
Mailing Address - Fax:843-847-3247
Practice Address - Street 1:9330 MEDICAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9104
Practice Address - Country:US
Practice Address - Phone:843-847-3225
Practice Address - Fax:843-847-3247
Is Sole Proprietor?:No
Enumeration Date:2005-11-26
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2011042174400000X
SC11042207RH0003X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3633Medicaid
SC110427Medicaid
SC7530Medicare ID - Type Unspecified
SCA47160Medicare UPIN
SCA471609223Medicare PIN