Provider Demographics
NPI:1578665618
Name:MICHALSKI, WALLACE J (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:J
Last Name:MICHALSKI
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 1:1211 HWY 31 NW
Mailing Address - Street 2:
Mailing Address - City:HARTSELLE
Mailing Address - State:AL
Mailing Address - Zip Code:35640
Mailing Address - Country:US
Mailing Address - Phone:256-773-6017
Mailing Address - Fax:256-773-7834
Practice Address - Street 1:1211 HWY 31 NW
Practice Address - Street 2:
Practice Address - City:HARTSELLE
Practice Address - State:AL
Practice Address - Zip Code:35640
Practice Address - Country:US
Practice Address - Phone:256-773-6017
Practice Address - Fax:256-773-7834
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8607207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51001788OtherBCBS
AL000001788Medicaid
AL51001788OtherBCBS
C72610Medicare UPIN