Healthcare Provider Details

I. General information

NPI: 1104394329
Provider Name (Legal Business Name): SCOTT C. WALLACE MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 ROSS AVE
EL CENTRO CA
92243-4306
US

IV. Provider business mailing address

PO BOX 112
MUNCIE IN
47308-0112
US

V. Phone/Fax

Practice location:
  • Phone: 301-305-5959
  • Fax:
Mailing address:
  • Phone: 765-284-0493
  • Fax: 765-284-2434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT C WALLACE
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 765-284-0493