Active NPI
Michael Wallace, DPT
- Physical Therapist
- Loganville, GA
National Provider Identifier
1881368561
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- PT015458
- Practice address
- 3440 Highway 81
Loganville, GA 30052-9112 - Phone
- (770) 554-5009
- Fax
- (706) 546-8792
- NPI assigned
- Aug 5, 2021
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | PT015458 | GA | Primary |
Addresses
Primary practice location
3440 Highway 81
Loganville, GA 30052-9112
Mailing address
1017 Crystal Brook Way
Monroe, GA 30655-7313
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 15426562 | Other | CAQH NUMBER |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PT015458 | GA | MD | Physical Therapist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Pediatric Orthopedic Associates | Past | Accepting new patients |
Organizations & group practices 1
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.
-
- Pediatric Radiology Physician
- Salt Lake City, UT
- NPI 1659488799
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1628121600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1710115200000",
"number": "1881368561",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1017 CRYSTAL BROOK WAY",
"city": "MONROE",
"state": "GA",
"postal_code": "306557313"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3440 HIGHWAY 81",
"city": "LOGANVILLE",
"state": "GA",
"postal_code": "300529112",
"telephone_number": "770-554-5009",
"fax_number": "706-546-8792"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "MICHAEL",
"name_prefix": "Mr.",
"credential": "DPT",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2021-08-05",
"last_updated": "2024-03-11",
"certification_date": "2024-03-11",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "GA",
"license": "PT015458",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "CAQH NUMBER",
"identifier": "15426562",
"state": null
}
],
"endpoints": [],
"other_names": []
}Other providers in Loganville, GA
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- Walton Children's Clinic
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Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 11, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.