Provider Demographics
NPI:1902869068
Name:WALL, JACK G (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:G
Last Name:WALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 11546
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37939-1546
Mailing Address - Country:US
Mailing Address - Phone:336-538-7000
Mailing Address - Fax:336-538-7547
Practice Address - Street 1:1240 HUFFMAN MILL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8700
Practice Address - Country:US
Practice Address - Phone:336-538-7000
Practice Address - Fax:336-538-7547
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC160372085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC85385OtherBCBS
NC8985385Medicaid
NC213352AMedicare PIN
NC8985385Medicaid