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General NPI Number Information
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NPI Number | 1942623939
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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 | 01/27/2014
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Last Update Date | 01/27/2014
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Provider Practice Location Address
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Address Line | 1986 E GLACIER PL
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City | CHANDLER
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State | AZ
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Zip | 85249-2886
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Country | US
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Telephone | 520-245-7379
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Fax | 888-700-8257
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Provider Business Mailing Address
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Address Line | 1986 E GLACIER PL
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City | CHANDLER
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State | AZ
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Zip | 85249-2886
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Country | US
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Telephone |
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Fax | 888-700-8257
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | ROBERT WALLACE
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Credential | BS
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Telephone | 520-245-7379
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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 |
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License Number State |
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