1144527870 NPI number — WALLACE PHYSICIAN SERVICES LLC

Table of content: (NPI 1144527870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144527870 NPI number — WALLACE PHYSICIAN SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALLACE PHYSICIAN SERVICES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144527870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40535
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45240-0535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-384-9045
Provider Business Mailing Address Fax Number:
859-212-0949

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1577 GOODMAN AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45224-1044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-403-3762
Provider Business Practice Location Address Fax Number:
513-521-6403
Provider Enumeration Date:
02/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WALLACE
Authorized Official First Name:
WAYMON
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
513-674-9601

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  35-076674 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com