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General NPI Number Information
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NPI Number | 1568422012
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Entity Type | Individual
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Provider Name | JONATHAN WALLACE M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/27/2006
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Last Update Date | 03/19/2021
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Provider Practice Location Address
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Address Line | 4885 HOFFMAN BLVD SUITE 400
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City | HOFFMAN ESTATES
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State | IL
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Zip | 60192-3726
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Country | US
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Telephone | 847-255-9697
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Fax | 847-255-9697
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Provider Business Mailing Address
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Address Line | 4885 HOFFMAN BLVD SUITE 400
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City | HOFFMAN ESTATES
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State | IL
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Zip | 60192-3726
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Country | US
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Telephone | 847-255-9697
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Fax | 847-255-9697
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 036108563
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 036108563
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License Number State | IL
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