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General NPI Number Information
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NPI Number | 1922044502
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Entity Type | Individual
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Provider Name | PERRY WALLACE MD
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Gender | Male
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Dates
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Enumeration Date | 06/21/2006
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Last Update Date | 11/14/2011
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Provider Practice Location Address
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Address Line | 2121 5TH ST SUITE 202
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City | MERIDIAN
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State | MS
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Zip | 39301-5108
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Country | US
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Telephone | 601-286-3410
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Fax | 601-286-3425
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Provider Business Mailing Address
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Address Line | 4156 A PL
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City | MERIDIAN
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State | MS
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Zip | 39301-1037
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Country | US
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Telephone | 662-402-0608
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Fax | 601-286-3425
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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 | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 29610
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 10491
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License Number State | MS
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 10491
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License Number State | MS
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Taxonomy #4
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 13895
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License Number State | AL
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