Basic Information
| Provider Information | |||||||||
| NPI: | 1417977646 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | STEPHENIE | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 703 VOLKER HALL | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352940001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059399345 | ||||||||
| FaxNumber: | 2059757307 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 7TH AVE S | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352331711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059399345 | ||||||||
| FaxNumber: | 2059757307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 01/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 25999 | AL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 009958245 | 05 | AL | MEDICAID | 009958265 | 05 | AL | MEDICAID |