NPIMap

Individual provider Active NPI

John Gray Wallace, M.D.

  • Family Medicine Physician
  • Kosciusko, MS
National Provider Identifier
1831486596
Registry record updated Sep 22, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
22522 Issued in MS
Practice address
332 Highway 12 W
Kosciusko, MS 39090-3209
Phone
(662) 289-1800
Fax
(662) 289-2486
NPI assigned
Jul 1, 2011
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 22, 2014

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 22522 MS Primary

Addresses

Primary practice location

332 Highway 12 W
Kosciusko, MS 39090-3209

Mailing address

PO Box 23996
Jackson, MS 39225-3996
Phone (601) 206-6100

Other identifiers 1

IdentifierTypeStateIssuer
07830815MedicaidMS

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS
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
I20130827000525 MS Practitioner - Family Practice 3072756808 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Mississippi School of Medicine, 2011
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Premier Medical Group of Mississippi LLCGroup PAC ID 8729973623, 31 clinicians

Practice addresses (Care Compare)

332 Hwy 12 W
Kosciusko, MS 39090-3209
Phone (662) 289-1800

Hospital & facility affiliations

  • Accentcare Home Health of Carthage Home health agency, Carthage, MS, CCN 257129
  • Mississippi Homecare of Eupora Home health agency, Eupora, MS, CCN 257122
  • Accentcare Home Health of Greenwood Home health agency, Greenwood, MS, CCN 257131
  • Accentcare Hospice & Palliative Care of Ms Hospice, Flowood, MS, CCN 251511
  • Baptist Medical Center Attala Hospital, Kosciusko, MS, CCN 251336
  • Mississippi Baptist Medical Center Hospital, Jackson, MS, CCN 250102
  • Attala County Nursing Center Nursing home, Kosciusko, MS, CCN 255191
  • Baptist Medical Center Attala Nursing home, CCN 25Z336

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions19
Removal or shaving of skin growth1-10

National Provider Directory

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

Practice roles

OrganizationSpecialtyStatusNew patients
Premier Medical Group of Mississippi LLC CurrentSince Aug 1, 2014 Accepting new patients
BMC - Attala, LLC Past Accepting new patients
Premier Medical Group of Mississippi LLC Past Accepting new patients
Attala Community Care Center LLC Past Accepting new patients

Locations

300 S Pearl St
#B
Carthage, MS 39051
Phone (601) 298-0333

59 Montague St
Goodman, MS 39079
Phone (662) 739-6040

530 Veterans Memorial Dr
Kosciusko, MS 39090
Phone (662) 289-9155

332 Highway 12 W
Kosciusko, MS 39090
Phone (601) 206-6100

Interoperability endpoints

  • Direct secure messaging: john.wallace.1@27768.direct.athenahealth.com

Ownership & related parties

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Baptist Medical Center - AttalaKosciusko, MS, CCN 251336 Hospital Corporate Director Dec 16, 2020
Baptist Medical Center - AttalaKosciusko, MS, CCN 25Z336 Hospital Corporate Director Dec 16, 2020
Baptist Medical Group - Kosciusko Primary CareKosciusko, MS, CCN 258614 Rural health clinic Corporate Director Mar 23, 2021

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

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 8

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": "1309478400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1411344000000",
    "number": "1831486596",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 23996",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392253996",
            "telephone_number": "601-206-6100",
            "fax_number": "601-206-6052"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "332 HIGHWAY 12 W",
            "city": "KOSCIUSKO",
            "state": "MS",
            "postal_code": "390903209",
            "telephone_number": "662-289-1800",
            "fax_number": "662-289-2486"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "JOHN",
        "middle_name": "GRAY",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2011-07-01",
        "last_updated": "2014-09-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MS",
            "license": "22522",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "07830815",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Kosciusko, MS

Sources for this page

Verify at the official NPI Registry.