GREGORY WALLACE (NPI# 1558701250) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1558701250 |
| Entity Type | Individual |
| Full Name | GREGORY WALLACE |
| Credential | D.O. |
| Practice Address |
11050 Mount Belvedere Blvd Fort Drum NY 13602 |
| Mailing Address |
11050 Mount Belvedere Blvd Fort Drum NY 13602-5438 |
| Practice Telephone | 3157725662 |
| Enumeration Date | 2013-06-27 |
| Last Update Date | 2018-07-27 |
| Gender Code | M |
| Is Sole Proprietor | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 207Q00000X | Family Medicine | 02004547A | IN | Allopathic & Osteopathic Physicians |
| N | 390200000X | Student in an Organized Health Care Education/Training Program | Student, Health Care |
| Address | Telephone Number | Fax Number |
|---|---|---|
| 2817 Reilly St, Womack Army Medical Center, Fort Bragg, NC 283107324 | 9109078922 | 9109076069 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1265902092 | Gregory Stephen Wallace | Family Medicine | 1042 Mason Woods Dr Ne, Atlanta, GA 30329-3802 | 2018-12-05 |
| 1073902250 | Gregory Roy Wallace | Rehabilitation Practitioner | 14545 Sherman Cir, Van Nuys, CA 91405-3087 | 2015-01-12 |
| 1770712309 | Gregory L. Wallace | Anesthesiology | 204 Mccollum Dr, Suite 101, Laramie, WY 82070-5151 | 2009-07-02 |
| 1992915532 | Gregory Wallace | Case Manager/Care Coordinator | 2707 Browns Ln, Jonesboro, AR 72401-7213 | 2007-05-23 |
| 1700898012 | Gregory Wallace | Social Worker | 6123 Montrose Rd, Rockville, MD 20852 | 2006-08-13 |
| 1346284957 | Gregory Hall Wallace | Pediatrics | 4623 Wesley Ave, Bmf Pediatric Care Suite G, Norwood, OH 45212 | 2006-06-15 |
| Street Address |
11050 MOUNT BELVEDERE BLVD |
| City | FORT DRUM |
| State | NY |
| Zip Code | 13602 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1760471932 | Randall Alan Bischoff | Physician Assistant | 11050 Mount Belvedere Blvd, Fort Drum, NY 13602-5438 | 2005-10-19 |
| 1619582657 | Tarah Schmidt | Student in an Organized Health Care Education/Training Program | 11050 Mount Belvedere Blvd, Fort Drum, NY 13602-5438 | 2020-09-15 |
| 1538778832 | Daniel L Dettman | Physical Therapist | 11050 Mount Belvedere Blvd, Fort Drum, NY 13602-5438 | 2020-07-23 |
| 1942836978 | Christie Hurst | Licensed Practical Nurse | 11050 Mount Belvedere Blvd, Fort Drum, NY 13602-5438 | 2020-03-21 |
| 1679033112 | Taylor Nichole Singer | Psychologist | 11050 Mount Belvedere Blvd, Fort Drum, NY 13602-5438 | 2019-03-21 |
| 1134692361 | Drew Curtis Evans | Physician Assistant | 11050 Mount Belvedere Blvd, Fort Drum, NY 13602-5438 | 2019-01-10 |
| 1457834814 | Timothy Karnuth | Physician Assistant | 11050 Mount Belvedere Blvd, Fort Drum, NY 13602-5438 | 2018-09-12 |
| 1598248262 | Oscar Alfredo Garzon | Student in an Organized Health Care Education/Training Program | 11050 Mount Belvedere Blvd, Fort Drum, NY 13602-5438 | 2018-09-10 |
| 1912484684 | Jacob Papenfuss | Physical Therapist | 11050 Mount Belvedere Blvd, Fort Drum, NY 13602-5438 | 2018-07-25 |
| 1285124644 | Marjorie A Evans | Physician Assistant | 11050 Mount Belvedere Blvd, Fort Drum, NY 13602-5438 | 2018-05-11 |
| Find all providers in the same location | ||||
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1235697590 | Joshua Lee Hickman | Physician Assistant | Bldg P10506 Euphrates River Valley Rd, Fort Drum, NY 13602 | 2019-03-06 |
| 1447721345 | Lisa Marie Lewis | Social Worker | 11044 Mount Belvedere Blvd, Fort Drum, NY 13602 | 2018-12-17 |
| 1720555253 | Elizabeth M Hover | Social Worker | P11050 Mt Belvedere Blvd, Fort Drum, NY 13602 | 2018-11-02 |
| 1376037424 | Phillip Dakotah Mitchell | Physician Assistant | 10020 Euphrates River Valley Road, Fort Drum, NY 13602 | 2018-06-20 |
| 1063902666 | Guthrie Ahc | Clinic/Center | P19914 M3r Tampa, Fort Drum, NY 13602 | 2018-05-18 |
| 1255846879 | Morgan Elizabeth Callari | Dental Hygienist | 10205 S Riva Ridge Loop, Fort Drum, NY 13602 | 2017-12-05 |
| 1609389097 | John Charles Bockmann | Physician Assistant | Connor Troop Medical Clinic, 10506 Euphrates River Valley Rd, Fort Drum, NY 13602 | 2017-11-08 |
| 1902318207 | Nicholas Andrew Jones | Military Health Care Provider | 10506 S. Riva Ridge, Fort Drum, NY 13602 | 2017-10-26 |
| 1508389198 | Richard Scott Christiansen | Physical Therapist | 10330 S Riva Ridge Loop, Fort Drum, NY 13602 | 2017-07-25 |
| 1811418098 | Emer B Bajuelos | Dentist | Ft Drum W07uaa 10590, Ft Drum, Apo, AP 13602 | 2017-06-28 |
| Find all providers in zip 13602 | ||||
| Taxonomy Code | 207Q00000X |
| Grouping | Allopathic & Osteopathic Physicians |
| Classification | Family Medicine |
| Family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family medicine is not limited by age, sex, organ system, or disease entity. |
| Notes: Source: American Board of Family Medicine [1/1/2007: changed title; 7/1/2007: added definition, added source; 7/1/2017: modified definition] - Note: The American Osteopathic Board of Family Physicians certification includes extensive use of Osteopathic Manipulative Treatment (OMT), which integrates the biological, clinical, and behavioral sciences. - Additional Resources: American Board of Family Medicine, www.theabfm.org. American Osteopathic Board of Family Physicians, www.osteopathic.org/certification - Board certification for Medical Doctors (MDs) is provided by the American Board of Family Medicine. Board certification for Doctors of Osteopathy (DOs) is provided by the American Osteopathic Board of Family Physicians or the American Board of Family Medicine. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1467999425 | Adam Stone Gardner | Family Medicine | Usameddac 11050 Mount Belvedere Blvd, Fort Drum, NY 13602-5004 | 2017-01-27 |
| 1144411596 | Colette Rajner | Family Medicine | 11050 Mount Belvedere Boulevard, Fort Drum, NY 13602-5004 | 2007-08-09 |
| 1992795686 | Dennis M Sullivan | Family Medicine | Ctmc, Us Army Meddac, Fort Drum, NY 13602 | 2005-10-25 |
| 1821088634 | Edward Hutchins Bailey | Family Medicine | P-10506 Second Street, Fort Drum, NY 13602 | 2005-10-24 |
| 1851817407 | Jorden Daniel Pope | Family Medicine | 11050 Mount Belvedere Blvd, Fort Drum, NY 13602-5438 | 2017-08-16 |
| 1912434903 | Justin Stewart | Family Medicine | 11050 Mount Belvedere Blvd, Fort Drum, NY 13602-5438 | 2017-05-22 |
| 1023561107 | Isaac P Mills | Family Medicine | 11050 Mount Belvedere Blvd, Fort Drum, NY 13602 | 2016-07-26 |
| 1356791537 | Jordan Joseph Gass | Family Medicine | 11050 Mount Belvedere Blvd, Fort Drum, NY 13602-5438 | 2016-06-17 |
| 1447665732 | Richard Zachary Haney | Family Medicine | 11050 Mount Belvedere Blvd, Fort Drum, NY 13602-5438 | 2014-06-25 |
| 1366853863 | Stephen Robert Vogel | Family Medicine | 11050 Mount Belvedere Blvd, Fort Drum, NY 13602-5438 | 2014-05-19 |
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.