Provider Demographics
NPI:1932192556
Name:WALLACE, MICHAEL C (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
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:PO BOX 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7685 WINCHESTER RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-2202
Practice Address - Country:US
Practice Address - Phone:901-752-6963
Practice Address - Fax:901-751-5540
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD36875207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1474033OtherCIGNA
TN4065344OtherBCBS, TN
TN7128500OtherAETNA
TNP00023565Medicare PIN
H85485Medicare UPIN
TN4065344OtherBCBS, TN