Healthcare Provider Details

I. General information

NPI: 1902908718
Provider Name (Legal Business Name): JAMES M WALLACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 E STATE ST
SAINT CROIX FALLS WI
54024-4117
US

IV. Provider business mailing address

235 E STATE ST
SAINT CROIX FALLS WI
54024-4117
US

V. Phone/Fax

Practice location:
  • Phone: 715-483-3221
  • Fax: 715-483-0507
Mailing address:
  • Phone: 715-483-3221
  • Fax: 715-483-0507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number37316
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number37316
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: