Basic Information
| Provider Information | |||||||||
| NPI: | 1386627040 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9330 MEDICAL PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438473225 | ||||||||
| FaxNumber: | 8438473247 | ||||||||
| Practice Location | |||||||||
| Address1: | 9330 MEDICAL PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438473225 | ||||||||
| FaxNumber: | 8438473247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2005 | ||||||||
| LastUpdateDate: | 05/09/2013 | ||||||||
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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 | 174400000X | 2011042 | SC | N | Other Service Providers | Specialist | 207RH0003X | 11042 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207R00000X | 11042 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP3633 | 05 | SC | MEDICAID | 110427 | 05 | SC | MEDICAID |