NPIMap

Individual provider Active NPI

William Robert Wallace, M.D.

  • Emergency Medicine Physician
  • Lexington, KY
National Provider Identifier
1851740609
Registry record updated Mar 29, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Emergency Medicine PhysicianTaxonomy code 207P00000X
License
55629 Issued in KY
Practice address
1221 S Broadway
Lexington, KY 40504-2701
Phone
(859) 258-4000
Fax
(859) 258-6203
NPI assigned
Jun 11, 2016
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Mar 29, 2023

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 2016015671 MO
Emergency Medicine Physician 207P00000X 55629 KY Primary

Addresses

Primary practice location

1221 S Broadway
Lexington, KY 40504-2701

Mailing address

1221 S Broadway
Lexington, KY 40504-2701
Phone (859) 258-4000

Other practice location 1

20828 W Deer Ridge Dr
Warrenton, MO 63383-6548
Phone (731) 693-1601

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY
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
I20210701003765 KY Practitioner - Emergency Medicine 9739472572 Reassigns benefits to 5 organizations

Care Compare profile

Medicare Care Compare
Specialty
Emergency Medicine
Education
Other, 2016
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Southeastern Emergency Physicians LLCGroup PAC ID 2466364997, 776 clinicians

Practice addresses (Care Compare)

4305 New Shepherdsville Rd
Bardstown, KY 40004-9019
Phone (502) 350-5000

Hospital & facility affiliations

National Provider Directory

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

State licenses

LicenseStateTypeSpecialty
2016015671MOMDInternal Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Southeastern Emergency Physicians LLC Emergency Medicine CurrentSince Jul 1, 2021 Accepting new patients
New Lexington Clinic PSC CurrentSince Apr 17, 2023 Accepting new patients
New Lexington Clinic, PSC Internal Medicine CurrentSince Apr 17, 2023 Accepting new patients
South Central Physicians PLLC CurrentSince Aug 10, 2021 Accepting new patients

Locations

4305 New Shepherdsville Rd
Bardstown, KY 40004
Phone (502) 350-5000

1700 Old Lebanon Rd
Campbellsvlle, KY 42718
Phone (270) 465-3561

1 Trillium Way
Corbin, KY 40701
Phone (606) 523-8521

1 Saint Joseph Dr
Lexington, KY 40504
Phone (502) 350-5000

1221 S Broadway
Lexington, KY 40504
Phone (859) 258-4181

4604 US Highway 60 W
Morganfield, KY 42437
Phone (270) 389-5000

Interoperability endpoints

  • Direct secure messaging: william.wallace.1@15020.direct.athenahealth.com

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 and National Provider Directory roles.

Hospital & facility affiliations 28

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

View all 28

NPI Registry JSON

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

{
    "created_epoch": "1465603200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1680048000000",
    "number": "1851740609",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1221 S BROADWAY",
            "city": "LEXINGTON",
            "state": "KY",
            "postal_code": "405042701",
            "telephone_number": "859-258-4000",
            "fax_number": "859-258-6203"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1221 S BROADWAY",
            "city": "LEXINGTON",
            "state": "KY",
            "postal_code": "405042701",
            "telephone_number": "859-258-4000",
            "fax_number": "859-258-6203"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "20828 W Deer Ridge Dr",
            "address_purpose": "LOCATION",
            "city": "Warrenton",
            "state": "MO",
            "postal_code": "633836548",
            "country_code": "US",
            "telephone_number": "731-693-1601",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "WILLIAM",
        "middle_name": "ROBERT",
        "credential": "M.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2016-06-11",
        "last_updated": "2023-03-29",
        "certification_date": "2023-03-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "MO",
            "license": "2016015671",
            "primary": false
        },
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "KY",
            "license": "55629",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Lexington, KY

Sources for this page

Verify at the official NPI Registry.