NPIMap

Individual provider Active NPI

Gregory Wallace, D.O.

  • Family Medicine Physician
  • Fort Drum, NY
National Provider Identifier
1558701250
Registry record updated Jul 27, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
02004547A Issued in IN
Practice address
11050 Mount Belvedere Blvd
Fort Drum, NY 13602
Phone
(315) 772-5662
NPI assigned
Jun 27, 2013
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jul 27, 2018

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Student in an Organized Health Care Education/Training Program 390200000X
Family Medicine Physician 207Q00000X 02004547A IN Primary

Addresses

Primary practice location

11050 Mount Belvedere Blvd
Fort Drum, NY 13602

Mailing address

11050 Mount Belvedere Blvd
Fort Drum, NY 13602-5438

Other practice location 1

2817 Reilly St
Womack Army Medical Center
Fort Bragg, NC 28310-7324
Phone (910) 907-8922

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NJ
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
I20200330003754 NJ Practitioner - Family Practice 0446570782 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Philadelphia College of Osteopathic Medicine, 2013
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Advocare, LLCGroup PAC ID 3678562188, 383 clinicians

Practice addresses (Care Compare)

132 Grove St
Suite a
Haddonfield, NJ 08033-1224
Phone (856) 354-2211

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10

National Provider Directory

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

Practice roles

OrganizationSpecialtyStatusNew patients
Advocare, LLC Family Medicine CurrentSince May 1, 2020 Accepting new patients
Advocare , LLC CurrentSince May 1, 2020 Accepting new patients
Advocare , LLC Family Medicine Past Accepting new patients

Locations

132 Grove St
Ste A
Haddonfield, NJ 08033
Phone (856) 354-2211

401 Route 73 N
Ste 320
Marlton, NJ 08053
Phone (609) 471-1033

Interoperability endpoints

  • Direct secure messaging: gregory.wallace@advocaredoctors.eclinicaldirectplus.com

Organizations & group practices 3

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

Hospital & facility affiliations 7

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": "1372291200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1532649600000",
    "number": "1558701250",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11050 MOUNT BELVEDERE BLVD",
            "city": "FORT DRUM",
            "state": "NY",
            "postal_code": "136025438"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11050 MOUNT BELVEDERE BLVD",
            "city": "FORT DRUM",
            "state": "NY",
            "postal_code": "13602",
            "telephone_number": "315-772-5662"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2817 Reilly St",
            "address_2": "Womack Army Medical Center",
            "address_purpose": "LOCATION",
            "city": "Fort Bragg",
            "state": "NC",
            "postal_code": "283107324",
            "country_code": "US",
            "telephone_number": "910-907-8922",
            "fax_number": "910-907-6069",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "GREGORY",
        "credential": "D.O.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2013-06-27",
        "last_updated": "2018-07-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "IN",
            "license": "02004547A",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Drum, NY

Sources for this page

Verify at the official NPI Registry.