Basic Information
| Provider Information | |||||||||
| NPI: | 1629063854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGREW | ||||||||
| FirstName: | WALLACE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 23RD AVE N STE 300 | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153425900 | ||||||||
| FaxNumber: | 6153426084 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 23RD AVE N STE 300 | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153425900 | ||||||||
| FaxNumber: | 6153426084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 06/11/2015 | ||||||||
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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 | 207RG0100X | MD13612 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 3199910 | 05 | TN | MEDICAID | 6477311200 | 05 | KY | MEDICAID | 100015681 | 01 | TN | RAILROAD MEDICARE | OTHER |