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General NPI Number Information
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NPI Number | 1487624581
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Entity Type | Individual
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Provider Name | HUGH J WALLACE MD
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Gender | Male
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Dates
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Enumeration Date | 01/23/2006
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Last Update Date | 03/30/2011
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Provider Practice Location Address
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Address Line | 1010 BETHESDA CT
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City | WINSTON SALEM
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State | NC
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Zip | 27103-3019
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Country | US
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Telephone | 336-277-8800
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Fax | 336-277-8850
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Provider Business Mailing Address
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Address Line | PO BOX 75216
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City | CHARLOTTE
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State | NC
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Zip | 28275-0216
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Country | US
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Telephone | 336-718-7080
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Fax | 336-718-9622
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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 | 207RH0003X
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Taxonomy Name | Hematology & Oncology Physician
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License Number | 9701639
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License Number State | NC
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