Healthcare Provider Details

I. General information

NPI: 1528018314
Provider Name (Legal Business Name): THOMAS CRAVEN WALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1126 N CHURCH ST SUITE 300
GREENSBORO NC
27401-1000
US

IV. Provider business mailing address

1200 N ELM ST
GREENSBORO NC
27401-1004
US

V. Phone/Fax

Practice location:
  • Phone: 336-547-1700
  • Fax:
Mailing address:
  • Phone: 336-832-7000
  • Fax: 336-851-8427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number28097
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number28097
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: