Basic Information
| Provider Information | |||||||||
| NPI: | 1891771879 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLEY | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4622 COUNTRY CLUB RD | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271043770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367689535 | ||||||||
| FaxNumber: | 3367684155 | ||||||||
| Practice Location | |||||||||
| Address1: | 4622 COUNTRY CLUB RD | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271043770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367689535 | ||||||||
| FaxNumber: | 3367684155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 09/11/2008 | ||||||||
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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 | 208G00000X | 19421 | NC | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 8985520 | 05 | NC | MEDICAID |