Individual
DR. EDWARD ALTON WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
300 SINGLETON RIDGE RD, CONWAY, SC 29526-9142
(843) 669-5162
(843) 669-5162
Mailing address
3100 SPRING FOREST RD, SUITE 130, RALEIGH, NC 27616-2880
(919) 882-0705
(919) 873-9821
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
13597
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
135972
—
SC
01
—
570835798
STANDARD TAX ID
SC
05
—
5900433
—
NC
01
—
E0051
MEDCOST
SC
Enumeration date
01/25/2007
Last updated
12/21/2016
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