Healthcare Provider Details

I. General information

NPI: 1801117585
Provider Name (Legal Business Name): ADAM N WALLACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 12/15/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8201 EAST RIVERSIDE BOULEVARD MERCY HEALTH JAVON BAE HOSPITAL
ROCKFORD IL
61114-2300
US

IV. Provider business mailing address

2301 N LAKE DR STE 1104
MILWAUKEE WI
53211-4508
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-5000
  • Fax:
Mailing address:
  • Phone: 414-585-3223
  • Fax: 414-585-3229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number70505-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number61898
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberDR.0068906
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2015013114
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number319983
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036.148822
License Number StateIL
# 7
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number036.148822
License Number StateIL
# 8
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number70505
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: