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General NPI Number Information
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NPI Number | 1790968154
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Entity Type | Individual
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Provider Name | EDWIN RUSH WALLACE III MPT
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Gender | Male
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Dates
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Enumeration Date | 12/07/2007
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Last Update Date | 10/31/2024
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Provider Practice Location Address
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Address Line | 100 PLAINSBORO RD
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City | PLAINSBORO
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State | NJ
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Zip | 08536-1914
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Country | US
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Telephone | 571-370-3686
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Fax | 571-370-3687
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Provider Business Mailing Address
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Address Line | 100 PLAINSBORO RD
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City | PLAINSBORO
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State | NJ
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Zip | 08536-1914
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Country | US
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Telephone | 609-945-5724
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Fax |
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | CP031482T
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 2305005465
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License Number State | VA
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