Provider Demographics
NPI:1316496664
Name:WALLACE UROLOGY INC
Entity type:Organization
Organization Name:WALLACE UROLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:901-272-3200
Mailing Address - Street 1:1325 EASTMORELAND AVE STE 425
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-7541
Mailing Address - Country:US
Mailing Address - Phone:901-272-3200
Mailing Address - Fax:901-278-3441
Practice Address - Street 1:1325 EASTMORELAND AVE STE 425
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-7541
Practice Address - Country:US
Practice Address - Phone:901-272-3200
Practice Address - Fax:901-278-3441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN015359208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty