NPIMap

Organization Active NPI

Wallace Urgent Care LLC

  • Internal Medicine Physician
  • Wallace, NC
National Provider Identifier
1841259025
Registry record updated Jun 24, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
WALLACE URGENT CARE LLC
Practice address
112 Medical Village Dr
Unit F
Wallace, NC 28466-9999
Phone
(910) 552-1580
Fax
(910) 665-1780
NPI assigned
Mar 17, 2006
Last updated
Jun 24, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 24, 2025

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

Authorized official

Name
Dr. Kamran Goudarzi, M.D.NPI 1972562593
Title
Owner
Phone
(910) 552-1580

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X NU Primary
Physician Assistant 363A00000X NU
Nurse Practitioner 363L00000X NU

Addresses

Primary practice location

112 Medical Village Dr
Unit F
Wallace, NC 28466-9999

Mailing address

112 Medical Village Dr
Unit F
Wallace, NC 28466-9999
Phone (910) 552-1580

Other identifiers 2

IdentifierTypeStateIssuer
01736OtherNCNCBCBS PROVIDER NUMBER
7901736MedicaidNC

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080222000491 NC Part B Supplier - Clinic/Group Practice 6709967912 Receives reassigned benefits from 10 practitioners
Practice locations: Wallace, NC

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 13

NPI Registry JSON

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

{
    "created_epoch": "1142553600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750723200000",
    "number": "1841259025",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "112 MEDICAL VILLAGE DR",
            "address_2": "UNIT F",
            "city": "WALLACE",
            "state": "NC",
            "postal_code": "284669999",
            "telephone_number": "910-552-1580",
            "fax_number": "910-665-1780"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "112 MEDICAL VILLAGE DR",
            "address_2": "UNIT F",
            "city": "WALLACE",
            "state": "NC",
            "postal_code": "284669999",
            "telephone_number": "910-552-1580",
            "fax_number": "910-665-1780"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WALLACE URGENT CARE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-17",
        "last_updated": "2025-06-24",
        "certification_date": "2025-06-24",
        "status": "A",
        "authorized_official_last_name": "GOUDARZI",
        "authorized_official_first_name": "KAMRAN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "910-552-1580",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCBCBS PROVIDER NUMBER",
            "identifier": "01736",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7901736",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Wallace, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 24, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.