MEDICARE: DR. JILL AMY WALLACE-ROSS DO

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	207Q00000X	Family Medicine Physician	OS10880	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770722043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JILL AMY WALLACE-ROSS DO

Provider Business Mailing Address
First Line	:	3200 S. UNIVERSITY DRIVE
Second Line	:	ASSEMBLY BLDG. # 2 ROOM 202
City	:	FT. LAUDERDALE
State	:	FL
Zip	:	33328-2018
Country	:	US
Telephone Number	:	954-262-4343
Fax Number	:	954-262-2269

Provider Business Practice Location Address
First Line	:	3200 S. UNIVERSITY DRIVE
Second Line	:	SANFORD L. ZIFF BLDG.
City	:	FT. LAUDERDALE
State	:	FL
Zip	:	33328-2018
Country	:	US
Telephone Number	:	954-262-4100
Fax Number	:	954-262-2271

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

Provider Enumeration Date	:	02/11/2009
Last Update Date	:	02/15/2012

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