Provider Demographics
NPI:1700822822
Name:WALLACE, THOMAS EVERETT (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:EVERETT
Last Name:WALLACE
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 1:740 S LIMESTONE
Mailing Address - Street 2:L534, KENTUCKY CLNIC
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0284
Mailing Address - Country:US
Mailing Address - Phone:859-323-5045
Mailing Address - Fax:
Practice Address - Street 1:740 S LIMESTONE
Practice Address - Street 2:L543, KENTUCKY CLINIC
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0284
Practice Address - Country:US
Practice Address - Phone:859-323-5045
Practice Address - Fax:859-257-2418
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD23936207RC0200X
WV30857207RP1001X, 207RC0200X
KY43982207RP1001X, 207RC0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN33270961Medicaid
TN4123936OtherBCBS OF TENNESSEE
TN4158379OtherBLUE CROSS
IN201256750Medicaid
TNP00317082OtherRAILROAD MEDICARE
TN3327097Medicaid
TN30707611Medicaid
TN4123936OtherBCBS OF TENNESSEE
TNP00317082OtherRAILROAD MEDICARE
TN30707611Medicaid