Provider Demographics
NPI:1922044502
Name:WALLACE, PERRY (MD)
Entity type:Individual
Prefix:DR
First Name:PERRY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4156 A PL
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-1037
Mailing Address - Country:US
Mailing Address - Phone:662-402-0608
Mailing Address - Fax:601-286-3425
Practice Address - Street 1:2121 5TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-5108
Practice Address - Country:US
Practice Address - Phone:601-286-3410
Practice Address - Fax:601-286-3425
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29610207P00000X
MS10491207P00000X, 207R00000X
AL13895207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA417498226AMedicaid
TN3331790Medicaid
TN3331790Medicare ID - Type Unspecified
GA417498226AMedicaid
TN3331790Medicaid
MSC74283Medicare UPIN