Healthcare Provider Details

I. General information

NPI: 1417977646
Provider Name (Legal Business Name): STEPHENIE B WALLACE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 01/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 7TH AVE S
BIRMINGHAM AL
35233-1711
US

IV. Provider business mailing address

703 VOLKER HALL
BIRMINGHAM AL
35294-0001
US

V. Phone/Fax

Practice location:
  • Phone: 205-939-9345
  • Fax: 205-975-7307
Mailing address:
  • Phone: 205-939-9345
  • Fax: 205-975-7307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number25999
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: