Provider Demographics
NPI:1881657989
Name:WALLACE, DOUGLASS MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLASS
Middle Name:MICHAEL
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD FL 1
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4210
Practice Address - Country:US
Practice Address - Phone:864-455-7899
Practice Address - Fax:864-455-5474
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301073207P00000X
SC26820207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1354ROtherBCBS
SCQ01075Medicaid
NC891354RMedicaid
SCP01034006OtherRAILROAD MEDICARE
NCP00282526OtherRAILROAD MEDICARE
NC1354ROtherBCBS
SCQ01075Medicaid
NC891354RMedicaid
NCP00282526OtherRAILROAD MEDICARE