Active NPI
Charles T Wallace, MD
- Anesthesiology Physician
- Charleston, SC
National Provider Identifier
1881702736
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Anesthesiology Physician
- License
- 05733
- Practice address
- 171 Ashley Ave
Charleston, SC 29425-0001 - Phone
- (843) 792-1414
- NPI assigned
- Aug 29, 2006
- 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 |
|---|---|---|---|---|
| Anesthesiology Physician | 207L00000X | 05733 | SC | Primary |
Addresses
Primary practice location
171 Ashley Ave
Charleston, SC 29425-0001
Mailing address
PO Box 751461
Charlotte, NC 28275-1461
Phone (843) 792-1414
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 057333 | Medicaid | SC |
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
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 05733 | SC | MD | Anesthesiology Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156809600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1193011200000",
"number": "1881702736",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 751461",
"city": "CHARLOTTE",
"state": "NC",
"postal_code": "282751461",
"telephone_number": "843-792-1414"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "171 ASHLEY AVE",
"city": "CHARLESTON",
"state": "SC",
"postal_code": "294250001",
"telephone_number": "843-792-1414"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "CHARLES",
"middle_name": "T",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-08-29",
"last_updated": "2007-10-22",
"status": "A"
},
"taxonomies": [
{
"code": "207L00000X",
"taxonomy_group": "",
"desc": "Anesthesiology",
"state": "SC",
"license": "05733",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "057333",
"state": "SC"
}
],
"endpoints": [],
"other_names": []
}Other providers in Charleston, SC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 22, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.