Provider Demographics
NPI: | 1629063854 |
---|---|
Name: | MCGREW, WALLACE R (MD) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | WALLACE |
Middle Name: | R |
Last Name: | MCGREW |
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: | 330 23RD AVE N STE 300 |
Mailing Address - Street 2: | SUITE 300 |
Mailing Address - City: | NASHVILLE |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37203-1690 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 615-342-5900 |
Mailing Address - Fax: | 615-342-6084 |
Practice Address - Street 1: | 330 23RD AVE N STE 300 |
Practice Address - Street 2: | SUITE 300 |
Practice Address - City: | NASHVILLE |
Practice Address - State: | TN |
Practice Address - Zip Code: | 37203-1690 |
Practice Address - Country: | US |
Practice Address - Phone: | 615-342-5900 |
Practice Address - Fax: | 615-342-6084 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-09-14 |
Last Update Date: | 2015-06-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TN | MD13612 | 207RG0100X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TN | 3199910 | Medicaid | |
KY | 6477311200 | Medicaid | |
TN | 100015681 | Other | RAILROAD MEDICARE |
TN | 3199912 | Medicare PIN | |
TN | 100015681 | Other | RAILROAD MEDICARE |