NPIMap

Individual provider Active NPI

Lacie Victoria Wallace, MD

  • Family Medicine Physician
  • Mt Pleasant, SC
National Provider Identifier
1366018012
Registry record updated Sep 11, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
86050 Issued in SC
Practice address
1400 Hospital Dr
Mt Pleasant, SC 29464-3255
Phone
(843) 884-1341
Fax
(843) 884-1345
NPI assigned
Jun 2, 2021
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 11, 2024

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X LL86050 SC
Family Medicine Physician 207Q00000X 86050 SC Primary

Addresses

Primary practice location

1400 Hospital Dr
Mt Pleasant, SC 29464-3255

Mailing address

PO Box 751649
Charlotte, NC 28275-1649
Phone (888) 472-0043

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20241004000221 SC Practitioner - Family Practice 7719383553 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Brody School of Medicine at East Carolina University, 2021
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Roper Saint Francis Physicians NetworkGroup PAC ID 5193874824, 530 clinicians

Practice addresses (Care Compare)

1400 Hospital Dr
Mount Pleasant, SC 29464-3255
Phone (843) 884-1314

Hospital & facility affiliations

  • Mount Pleasant Hospital Hospital, Mount Pleasant, SC, CCN 420104
  • Roper Hospital Hospital, Charleston, SC, CCN 420087
  • Bon Secours-St Francis Xavier Hospital Hospital, Charleston, SC, CCN 420065
  • Musc Medical Center Hospital, Charleston, SC, CCN 420004
  • Novant Health East Cooper Medical Center Hospital, Mount Pleasant, SC, CCN 420089

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10
Removal or shaving of skin growth1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
86050SCMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Roper Saint Francis Physicians Network CurrentSince Sep 23, 2024 Accepting new patients
Roper Saint Francis Physicians Network Family Medicine CurrentSince Sep 23, 2024 Accepting new patients
Roper Saint Francis Physicians Network Current Accepting new patients
Roper Saint Francis Physicians Network Past Accepting new patients

Locations

1400 Hospital Dr
Mt Pleasant, SC 29464
Phone (843) 884-0301

2075 Eagle Landing Blvd
North Charleston, SC 29406
Phone (843) 797-5747

Interoperability endpoints

  • Direct secure messaging: lwallace2703663@direct.bsmhealth.org

Organizations & group practices 4

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.

Hospital & facility affiliations 10

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1622592000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1726012800000",
    "number": "1366018012",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 751649",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282751649",
            "telephone_number": "888-472-0043",
            "fax_number": "843-724-2440"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1400 HOSPITAL DR",
            "city": "MT PLEASANT",
            "state": "SC",
            "postal_code": "294643255",
            "telephone_number": "843-884-1341",
            "fax_number": "843-884-1345"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "LACIE",
        "middle_name": "VICTORIA",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2021-06-02",
        "last_updated": "2024-09-11",
        "certification_date": "2024-09-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "SC",
            "license": "LL86050",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "SC",
            "license": "86050",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Mt Pleasant, SC

Sources for this page

Verify at the official NPI Registry.