Individual
DOUGLASS MICHAEL WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
701 GROVE RD FL 1, GREENVILLE, SC 29605-4210
(864) 455-7899
(864) 455-5474
Mailing address
300 E MCBEE AVE FL 4, GREENVILLE, SC 29601-2842
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
200301073
NC
207P00000X
Emergency Medicine Physician
Primary
26820
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1354R
BCBS
NC
05
—
891354R
—
NC
01
—
P00282526
RAILROAD MEDICARE
NC
01
—
P01034006
RAILROAD MEDICARE
SC
05
—
Q01075
—
SC
Enumeration date
04/10/2006
Last updated
10/11/2022
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