Organization
CHARLES R. WALLACE, JR., MD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. ANN MARIE WALLACE (OFFICE MANAGER)
(901) 272-3200
Entity
Organization
Contact information
Practice address
1325 EASTMORELAND AVE STE 425, MEMPHIS, TN 38104-7541
(901) 272-3200
(901) 278-3441
Mailing address
1325 EASTMORELAND AVE STE 425, MEMPHIS, TN 38104-7541
(901) 272-3200
(901) 278-3441
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0040441
BCBS
TN
Enumeration date
06/24/2008
Last updated
06/24/2008
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