MEDICARE: MR. LAWRENCE WALLACE MD, PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	MD439714	PA
2	225100000X	Physical Therapist	P2177	NC
3	207X00000X	Orthopaedic Surgery Physician	0101234728	VA
4	225100000X	Physical Therapist	11194	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679567192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LAWRENCE WALLACE MD, PT

Provider Business Mailing Address
First Line	:	1021 2ND AVE N STE 6
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29582-3200
Country	:	US
Telephone Number	:	843-286-5168
Fax Number	:	844-318-8980

Provider Business Practice Location Address
First Line	:	1021 2ND AVE N STE 6
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29582-3200
Country	:	US
Telephone Number	:	843-286-5168
Fax Number	:	844-318-8980

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	01/26/2026

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