Healthcare Provider Details

I. General information

NPI: 1952306029
Provider Name (Legal Business Name): WALLACE F BURROUGHS II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 W MADISON AVE
ATHENS TN
37303-3498
US

IV. Provider business mailing address

1031 W MADISON AVE
ATHENS TN
37303-3498
US

V. Phone/Fax

Practice location:
  • Phone: 423-745-6575
  • Fax:
Mailing address:
  • Phone: 423-745-6575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD09614
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: