Basic Information
| Provider Information | |||||||||
| NPI: | 1487624581 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | HUGH | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 75216 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282750216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367187080 | ||||||||
| FaxNumber: | 3367189622 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 BETHESDA CT | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271033019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362778800 | ||||||||
| FaxNumber: | 3362778850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 03/30/2011 | ||||||||
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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 | 207RH0003X | 9701639 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 3603374 | 01 | UNITED HEALTHCARE | OTHER | 8910714 | 05 | NC | MEDICAID | 4652218 | 01 | AETNA PPO | OTHER | 10714 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 74692 | 01 | MEDCOST | OTHER | 006005403 | 05 | VA | MEDICAID | 20464 | 01 | PARTNERS | OTHER | 3131142 | 01 | AETNA HMO | OTHER |