MEDICARE: DR. WILLIAM J WALLACE D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207YS0123X	Facial Plastic Surgery Physician	01428	TN
2	207Y00000X	Otolaryngology Physician	39895	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275539603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM J WALLACE D.O.

Provider Business Mailing Address
First Line	:	PO BOX 6069
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29171-6069
Country	:	US
Telephone Number	:	803-936-7530
Fax Number	:	803-936-7532

Provider Business Practice Location Address
First Line	:	146 E HOSPITAL DR STE 200
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-4800
Country	:	US
Telephone Number	:	803-936-7530
Fax Number	:	803-936-7532

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	01/13/2026

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