Provider Demographics
NPI:1841215902
Name:WALLACE, TIMOTHY BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:BRIAN
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 1:6605 ABERCORN ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5815
Mailing Address - Country:US
Mailing Address - Phone:912-355-7214
Mailing Address - Fax:
Practice Address - Street 1:6605 ABERCORN ST
Practice Address - Street 2:SUITE 108
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5815
Practice Address - Country:US
Practice Address - Phone:912-355-7214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027684207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD46836Medicare UPIN