Individual
MICHAEL C WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
7685 WINCHESTER RD, MEMPHIS, TN 38125-2202
(901) 752-6963
(901) 751-5540
Mailing address
PO BOX 405827, ATLANTA, GA 30384-5800
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
MD36875
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1474033
CIGNA
TN
01
—
4065344
BCBS, TN
TN
01
—
7128500
AETNA
TN
Enumeration date
08/30/2005
Last updated
10/25/2016
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