1790968154 NPI number — MR. EDWIN RUSH WALLACE III MPT

Table of content: (NPI 1023254224)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790968154 NPI number — MR. EDWIN RUSH WALLACE III MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
EDWIN
Provider Middle Name:
RUSH
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
MPT
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:
1790968154
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 PLAINSBORO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLAINSBORO
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08536-1914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-945-5724
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 PLAINSBORO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLAINSBORO
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08536-1914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
571-370-3686
Provider Business Practice Location Address Fax Number:
571-370-3687
Provider Enumeration Date:
12/07/2007

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: 225100000X , with the licence number:  CP031482T , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 2305005465 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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