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General NPI Number Information
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NPI Number | 1255486452
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Entity Type | Individual
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Provider Name | EDWARD ALTON WALLACE MD
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Gender | Male
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Dates
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Enumeration Date | 01/25/2007
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Last Update Date | 12/21/2016
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Provider Practice Location Address
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Address Line | 300 SINGLETON RIDGE RD
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City | CONWAY
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State | SC
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Zip | 29526-9142
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Country | US
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Telephone | 843-669-5162
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Fax | 843-669-5162
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Provider Business Mailing Address
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Address Line | 3100 SPRING FOREST RD SUITE 130
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City | RALEIGH
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State | NC
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Zip | 27616-2880
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Country | US
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Telephone | 919-882-0705
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Fax | 919-873-9821
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 13597
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License Number State | SC
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