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General NPI Number Information
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NPI Number | 1437892676
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Entity Type | Individual
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Provider Name | WILLIAM ROBERT WALLACE MD
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Gender | Male
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Dates
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Enumeration Date | 04/15/2022
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Last Update Date | 07/16/2024
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Provider Practice Location Address
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Address Line | 1601 UNIVERSITY BLVD E
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City | TUSCALOOSA
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State | AL
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Zip | 35404-2920
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Country | US
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Telephone | 205-349-2273
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Fax |
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Provider Business Mailing Address
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Address Line | 850 PETER BRYCE BLVD
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City | TUSCALOOSA
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State | AL
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Zip | 35401-7457
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Country | US
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Telephone |
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Fax |
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | L.5697R
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License Number State | AL
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