Provider Demographics
NPI:1487624581
Name:WALLACE, HUGH J (MD)
Entity type:Individual
Prefix:DR
First Name:HUGH
Middle Name:J
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 75216
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-0216
Mailing Address - Country:US
Mailing Address - Phone:336-718-7080
Mailing Address - Fax:336-718-9622
Practice Address - Street 1:1010 BETHESDA CT
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3019
Practice Address - Country:US
Practice Address - Phone:336-277-8800
Practice Address - Fax:336-277-8850
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701639207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
3603374OtherUNITED HEALTHCARE
NC8910714Medicaid
4652218OtherAETNA PPO
NC10714OtherBLUE CROSS BLUE SHIELD
74692OtherMEDCOST
VA006005403Medicaid
20464OtherPARTNERS
3131142OtherAETNA HMO
NC2245595AMedicare ID - Type Unspecified
P00031292Medicare ID - Type UnspecifiedRAILROAD MEDICARE
NC8910714Medicaid