Basic Information
| Provider Information | |||||||||
| NPI: | 1225005069 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | SIDNEY | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 260 FORT SANDERS WEST BLVD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379223355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657694545 | ||||||||
| FaxNumber: | 8657694501 | ||||||||
| Practice Location | |||||||||
| Address1: | 260 FORT SANDERS WEST BLVD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379223355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655584400 | ||||||||
| FaxNumber: | 8657694536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 07/12/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD747 | TN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200030085 | 01 | TN | RAILROAD MEDICARE | OTHER | 3122938 | 05 | TN | MEDICAID | 4465401 | 01 | TN | AETNA | OTHER | TN0124 | 01 | TN | JOHN DEERE HEALTHCARE | OTHER | 100011199 | 01 | TN | TENNCARE | OTHER | 1201443 | 01 | TN | UNITED HEALTH CARE | OTHER | TN0153 | 01 | TN | JOHN DEERE HEALTHCARE | OTHER | 3071355 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER |