Healthcare Provider Details

I. General information

NPI: 1255486452
Provider Name (Legal Business Name): EDWARD ALTON WALLACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SINGLETON RIDGE RD
CONWAY SC
29526-9142
US

IV. Provider business mailing address

3100 SPRING FOREST RD SUITE 130
RALEIGH NC
27616-2880
US

V. Phone/Fax

Practice location:
  • Phone: 843-669-5162
  • Fax: 843-669-5162
Mailing address:
  • Phone: 919-882-0705
  • Fax: 919-873-9821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number13597
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: