Shana Dale Wallace, MD

Primary specialty

Neurology with Special Qualifications in Child Neurology PhysicianTaxonomy code 2084N0402X

License

200401063 Issued in NC

Practice address

1900 Randolph Rd
Suite 1010
Charlotte, NC 28207-1122

Phone

(704) 384-1390

Fax

(704) 384-1063

NPI assigned

Mar 13, 2007

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 2

Other names 1

• Dr. Shana Dale Green Former name

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in NC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

NeurologyAlso: Pediatric Medicine

Education

Other, 2002

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Novant Health Medical Group, LLCGroup PAC ID 1153234893, 2,413 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Novant Health Medical Group, LLC

  • Neurology with Special Qualifications in Child Neurology Physician
  • Charlotte, NC
  • NPI 1366409492

  Neurodevelopmental Disabilities

  Medicare reassignment Care Compare group NPD
• Novant Health Medical Group, LLC

  • Obstetrics & Gynecology Physician
  • Matthews, NC
  • NPI 1386506137
  NPD
• Novant Medical Group, Inc.

  • Neurology Physician
  • Charlotte, NC
  • NPI 1891271482
  NPD
• Novant Health Medical Group, LLC

  • Internal Medicine Physician
  • Charlotte, NC
  • NPI 1134841802
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1173744000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1603584000000",
    "number": "1013040666",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 60447",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282600447",
            "telephone_number": "704-384-1390",
            "fax_number": "704-384-1063"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1900 RANDOLPH RD",
            "address_2": "SUITE 1010",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282071122",
            "telephone_number": "704-384-1390",
            "fax_number": "704-384-1063"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "SHANA",
        "middle_name": "DALE",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-03-13",
        "last_updated": "2020-10-25",
        "certification_date": "2020-09-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2080P0008X",
            "taxonomy_group": "",
            "desc": "Pediatrics, Neurodevelopmental Disabilities",
            "state": "NC",
            "license": "2004-01063",
            "primary": false
        },
        {
            "code": "2084N0402X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Neurology with Special Qualifications in Child Neurology",
            "state": "NC",
            "license": "200401063",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5907566",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAL LICENSE",
            "identifier": "200401063",
            "state": "NC"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "swallace15255@direct.novanthealth.org",
            "affiliation": "N",
            "address_1": "1900 Randolph Rd",
            "address_2": "Suite 1010",
            "city": "Charlotte",
            "state": "NC",
            "country_code": "US",
            "postal_code": "282071122",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "first_name": "SHANA",
            "last_name": "GREEN",
            "middle_name": "DALE",
            "prefix": "DR.",
            "credential": "MD",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Noah Wallace
• Portia Dionne Wallace
• Robert Bowman Wallace, DPT
• Robert T Wallace, C.PED.
• Rubye Burks Wallace, RN
• Sidiqat Wallace
• Terry W Wallace, M.D.
• Tonia Wallace, PMHNP-BC
• Stephen Lee Wallenhaupt, MD
• Peter David Wallens, M.S.W.

• Neurology with Special Qualifications in Child Neurology Physician in Charlotte, NC
• Providers in Charlotte, NC by specialty
• Neurology with Special Qualifications in Child Neurology Physician in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 25, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.