=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669644514
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SABINA R WALLACH MD AMC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2008
-----------------------------------------------------
Last Update Date | 02/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9850 GENESEE AVE SUITE 400
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-1224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-558-8666
-----------------------------------------------------
Fax | 858-558-9233
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9850 GENESEE AVE SUITE 400
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-1224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-558-8666
-----------------------------------------------------
Fax | 858-558-9233
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SABINA R WALLACH
-----------------------------------------------------
Credential | MD, FRACP, FACP
-----------------------------------------------------
Telephone | 858-558-8666
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A34070
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------