NPIMap

Individual provider Active NPI

Andrew Blake Wallace, M.D.

  • Diagnostic Radiology Physician
  • Saint Louis, MO
National Provider Identifier
1740626654
Registry record updated May 5, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
License
2020-04583 Issued in NC
Practice address
510 S Kingshighway Blvd
Mallinckrodt Institue of Radiology
Saint Louis, MO 63110-1016
Phone
(314) 362-2978
NPI assigned
May 18, 2013
Last updated
May 5, 2021By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on May 5, 2021

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology Physician 2085R0202X 2020-04583 NC Primary
Diagnostic Radiology Physician 2085R0202X 2014013932 MO

Addresses

Primary practice location

510 S Kingshighway Blvd
Mallinckrodt Institue of Radiology
Saint Louis, MO 63110-1016

Mailing address

1025 Medical Center Dr
Wilmington, NC 28401-7354
Phone (910) 762-3882

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO, NC2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20180521000715 MO Practitioner - Diagnostic Radiology 1254552243 Reassigns benefits to 2 organizations
I20210510001536 NC Practitioner - Diagnostic Radiology 1254552243 Reassigns benefits to 3 organizations

Care Compare profile

Medicare Care Compare
Specialty
Diagnostic Radiology
Education
University of North Carolina at Chapel Hill School of Medicine, 2013
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Delaney Radiologists Group PLLCGroup PAC ID 4981684875, 55 clinicians
Delaney Radiologists PAGroup PAC ID 6305813684, 55 clinicians

Practice addresses (Care Compare)

1025 Medical Ctr Dr
Wilmington, NC 28401-7354
Phone (910) 762-3882

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
83.57 of 100Reported as group
Quality
80.67
Improvement activities
40

Merit-based Incentive Payment System (MIPS)

Final score
81.72 of 100Reported as group
Quality
88.57
Improvement activities
40
Cost
60.01

National Provider Directory

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

State licenses

LicenseStateTypeSpecialty
2014013932MOMDDiagnostic Radiology Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Miracl, LLC CurrentSince Dec 24, 2018 Accepting new patients
Wilmington ASC LLC CurrentSince Jul 1, 2021 Accepting new patients
Wilmington Health PLLC CurrentSince Jul 1, 2021 Accepting new patients
Delaney Radiologists PA CurrentSince Jul 1, 2021 Accepting new patients
Delaney Radiologists Group PLLC CurrentSince Jul 1, 2021 Accepting new patients
Washington University Diagnostic Radiology CurrentSince Jul 1, 2018 Accepting new patients

Locations

1000 W 10th St
Rolla, MO 65401
Phone (573) 364-9000

510 S Kingshighway Blvd
Saint Louis, MO 63110
Phone (314) 362-0177

510 S Kingshighway Blvd
#8131
Saint Louis, MO 63110
Phone (314) 362-2978

1025 Medical Center Dr
Wilmington, NC 28401
Phone (910) 762-3882

1202 Medical Center Dr
Wilmington, NC 28401
Phone (910) 617-6705

2131 S 17th St
Wilmington, NC 28401
Phone (910) 342-3000

Interoperability endpoints

  • Direct secure messaging: awallace880697@direct.novanthealth.org

Organizations & group practices 6

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 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": "1368835200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1620172800000",
    "number": "1740626654",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1025 MEDICAL CENTER DR",
            "city": "WILMINGTON",
            "state": "NC",
            "postal_code": "284017354",
            "telephone_number": "910-762-3882"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "510 S KINGSHIGHWAY BLVD",
            "address_2": "MALLINCKRODT INSTITUE OF RADIOLOGY",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631101016",
            "telephone_number": "314-362-2978"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "ANDREW",
        "middle_name": "BLAKE",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2013-05-18",
        "last_updated": "2021-05-05",
        "certification_date": "2021-05-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "NC",
            "license": "2020-04583",
            "primary": true
        },
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "MO",
            "license": "2014013932",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Saint Louis, MO

Sources for this page

Verify at the official NPI Registry.