1841289022 NPI number — DR. STEPHANIE R WALLACE MD

Table of content: DR. STEPHANIE R WALLACE MD (NPI 1841289022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841289022 NPI number — DR. STEPHANIE R WALLACE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
STEPHANIE
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1841289022
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 S CASCADE AVE STE 140
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80903-1604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-866-6568
Provider Business Mailing Address Fax Number:
719-538-2999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2405 RESEARCH PARKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-522-1134
Provider Business Practice Location Address Fax Number:
719-598-7229
Provider Enumeration Date:
10/19/2005

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: 208000000X , with the licence number:  DR.0034435 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01344357 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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