Healthcare Provider Details

I. General information

NPI: 1437685914
Provider Name (Legal Business Name): SIMON ANDREW WALLACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 LIPPINCOTT DR
MARLTON NJ
08053-4805
US

IV. Provider business mailing address

301 LIPPINCOTT DR STE 410
MARLTON NJ
08053-4197
US

V. Phone/Fax

Practice location:
  • Phone: 856-355-7155
  • Fax: 856-325-4798
Mailing address:
  • Phone: 856-355-7155
  • Fax: 856-325-4798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number7636-851
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number72026
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number25MA12907600
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number25MA12907600
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberMD477813
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: