1992826358 NPI number — DR. DANYALE A WALLACE M.D.

Table of content: DR. DANYALE A WALLACE M.D. (NPI 1992826358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992826358 NPI number — DR. DANYALE A WALLACE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
DANYALE
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1992826358
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 W NORTH AVE
Provider Second Line Business Mailing Address:
APT. 302
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60610-1248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-274-9694
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 W POLK STREET
Provider Second Line Business Practice Location Address:
FLOOR 10
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-964-0060
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/03/2007

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: 207P00000X , with the licence number:  336076552 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 217008 . This is a "MEDICARE GROUP #" identifier . This identifiers is of the category "OTHER".




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