Basic Information
| Provider Information | |||||||||
| NPI: | 1700822822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | EVERETT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 S LIMESTONE | ||||||||
| Address2: | L534, KENTUCKY CLNIC | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405360284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593235045 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 740 S LIMESTONE | ||||||||
| Address2: | L543, KENTUCKY CLINIC | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405360284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593235045 | ||||||||
| FaxNumber: | 8592572418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | MD23936 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 30857 | WV | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | 43982 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | 43982 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207R00000X | 43982 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 30857 | WV | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 33270961 | 05 | TN | MEDICAID | 4123936 | 01 | TN | BCBS OF TENNESSEE | OTHER | 4158379 | 01 | TN | BLUE CROSS | OTHER | 201256750 | 05 | IN | MEDICAID | P00317082 | 01 | TN | RAILROAD MEDICARE | OTHER | 3327097 | 05 | TN | MEDICAID | 30707611 | 05 | TN | MEDICAID |