Healthcare Provider Details

I. General information

NPI: 1831516491
Provider Name (Legal Business Name): GRANT MEYER WALLACE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2014
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S 48TH ST
LINCOLN NE
68506-1283
US

IV. Provider business mailing address

700 CHILDRENS DR
COLUMBUS OH
43205-2664
US

V. Phone/Fax

Practice location:
  • Phone: 402-483-3333
  • Fax:
Mailing address:
  • Phone: 614-722-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number35718
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: