MEDICARE: DR. WAYNE ARNOLD WALLACE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	108875	NY

General Provider Information

NPI Number	:	1346340031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WAYNE ARNOLD WALLACE M.D.

Provider Business Mailing Address
First Line	:	9521 CRYSTAL BEACH RD
Second Line	:
City	:	HAMMONDSPORT
State	:	NY
Zip	:	14840-9340
Country	:	US
Telephone Number	:	607-292-3505
Fax Number	:	607-292-3505

Provider Business Practice Location Address
First Line	:	9521 CRYSTAL BEACH RD
Second Line	:
City	:	HAMMONDSPORT
State	:	NY
Zip	:	14840-9340
Country	:	US
Telephone Number	:	607-292-3505
Fax Number	:	607-292-3505

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2006
Last Update Date	:	07/08/2007

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