Provider Demographics
NPI:1497473557
Name:WALLACE PLASTIC SURGERY GROUP, PLLC
Entity Type:Organization
Organization Name:WALLACE PLASTIC SURGERY GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-779-6538
Mailing Address - Street 1:1065 TIDES RIDGE CV
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2625
Mailing Address - Country:US
Mailing Address - Phone:901-779-6538
Mailing Address - Fax:
Practice Address - Street 1:1000 BROOKFIELD RD STE 100
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0853
Practice Address - Country:US
Practice Address - Phone:901-779-6538
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty