1679567192 NPI number — MR. LAWRENCE WALLACE MD

Table of content: MR. LAWRENCE WALLACE MD (NPI 1679567192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679567192 NPI number — MR. LAWRENCE WALLACE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
LAWRENCE
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1679567192
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1225 WARM SPRINGS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGDON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16652-2350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-643-8556
Provider Business Mailing Address Fax Number:
814-643-7014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
790 BRYAN ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
HUNTINGDON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16652-2410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-643-8484
Provider Business Practice Location Address Fax Number:
814-643-8487
Provider Enumeration Date:
09/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  0101234728 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207X00000X , with the licence number: MD439714 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 010114446 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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