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General NPI Number Information
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NPI Number | 1144527870
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Entity Type | Organization
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Legal Business Name | WALLACE PHYSICIAN SERVICES LLC
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Dates
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Enumeration Date | 02/15/2011
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1577 GOODMAN AVE STE A
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City | CINCINNATI
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State | OH
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Zip | 45224-1044
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Country | US
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Telephone | 513-403-3762
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Fax | 513-521-6403
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Provider Business Mailing Address
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Address Line | PO BOX 40535
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City | CINCINNATI
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State | OH
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Zip | 45240-0535
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Country | US
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Telephone | 859-384-9045
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Fax | 859-212-0949
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. WAYMON L WALLACE
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Credential | M.D.
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Telephone | 513-674-9601
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 35-076674
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License Number State | OH
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