Provider Demographics
NPI:1700920154
Name:WALLACE, WILLIAM FREDRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:FREDRICK
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 1:11700 MERCY BLVD
Mailing Address - Street 2:BLVD 6
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-1753
Mailing Address - Country:US
Mailing Address - Phone:912-927-3434
Mailing Address - Fax:
Practice Address - Street 1:11700 MERCY BLVD
Practice Address - Street 2:BUILDING 6
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1753
Practice Address - Country:US
Practice Address - Phone:912-927-3434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060513207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA581114452AMedicaid
GA1700920154OtherMEDICARE RAILROAD
GA1700920154OtherMEDICARE RAILROAD