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General NPI Number Information
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NPI Number | 1154422343
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Entity Type | Organization
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Legal Business Name | WALLACE MEDICAL GROUP
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Dates
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Enumeration Date | 09/26/2006
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Last Update Date | 10/11/2007
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Provider Practice Location Address
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Address Line | 8920 WILSHIRE BLVD #327
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City | BEVERLY HILLS
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State | CA
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Zip | 90211-2007
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Country | US
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Telephone | 310-652-8460
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Fax | 310-652-8499
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Provider Business Mailing Address
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Address Line | 8920 WILSHIRE BLVD #327
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City | BEVERLY HILLS
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State | CA
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Zip | 90211-2003
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Country | US
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Telephone | 310-652-8460
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Fax | 310-652-8499
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Authorized Official
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Title or Position | PRESIDENT
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Name | PAUL WESLEY WALLACE
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Credential | M.D.
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Telephone | 310-652-8460
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | A49918
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License Number State | CA
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