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General NPI Number Information
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NPI Number | 1245602069
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Entity Type | Organization
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Legal Business Name | FLEMING ISLAND PLASTIC SURGERY LLC
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Dates
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Enumeration Date | 10/21/2015
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Last Update Date | 09/13/2024
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Provider Practice Location Address
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Address Line | 1715 EAGLE HARBOR PKWY STE B
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City | FLEMING ISLAND
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State | FL
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Zip | 32003-4324
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Country | US
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Telephone | 904-990-3477
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Fax | 904-621-9272
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Provider Business Mailing Address
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Address Line | 916 ALAMEDA LN
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City | SAINT JOHNS
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State | FL
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Zip | 32259-6903
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Country | US
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Telephone | 904-348-0727
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Fax | 904-621-9272
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Authorized Official
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Title or Position | MANAGER/OWNER
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Name | DR. WILLIAM WALLACE
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Credential | MD
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Telephone | 904-990-3477
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0122X
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Taxonomy Name | Plastic and Reconstructive Surgery Physician
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License Number | ME107749
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License Number State | FL
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