Basic Information
| Provider Information | |||||||||
| NPI: | 1437113784 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOYD | ||||||||
| FirstName: | WALLACE | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976044 | ||||||||
| FaxNumber: | 8647976198 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 MEDICAL PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GREER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296502456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644547422 | ||||||||
| FaxNumber: | 8647979701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 05/04/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 5343 | SC | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 053435 | 05 | SC | MEDICAID |