MEDICARE: DR. PHILIP A WALLER 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	207RR0500X	Rheumatology Physician	J3933	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5214420001	OTHER	TX	DME
2	8AW783	OTHER	TX	BCBS
3	P00063802	OTHER	TX	RRMC

General Provider Information

NPI Number	:	1588630578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHILIP A WALLER M.D.

Provider Business Mailing Address
First Line	:	11003 RESOURCE PKWY STE 102
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77089-6142
Country	:	US
Telephone Number	:	281-481-8557
Fax Number	:	281-484-7916

Provider Business Practice Location Address
First Line	:	11003 RESOURCE PKWY STE 102
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77089-6142
Country	:	US
Telephone Number	:	281-481-8557
Fax Number	:	281-484-7916

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

Provider Enumeration Date	:	02/28/2006
Last Update Date	:	06/22/2022

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