Physician Compare National (NPI:1629089156)

HEALTHCARE PROVIDER: JEFFREY S WALLACE M.D.

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1629089156
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	4486632031
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20050114000500
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	WALLACE
	Individual professional last name
Provider First Name	JEFFREY
	Individual professional first name
Provider Middle Name	S
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.
Provider Credential Text	MD
	The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS.

Medical School Information
Medical School Name	LOUISIANA STATE UNIVERSITY SCHOOL OF MEDICINE IN SHREVEPORT
	Individual professional's medical school
Graduation Year	1991
	Individual professional's medical school graduation year
Primary Specialty	ORTHOPEDIC SURGERY
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Line 1 Street Address	6701 HERITAGE PKWY
	Group Practice or individual's line 1 address
Line 2 Street Address	SUITE 140
	Group Practice or individual's line 2 address
City	ROCKWALL
	Group Practice or individual's city
State	TX
	Group Practice or individual's state
Zip Code	750878799
	Group Practice or individual's zip code (9 digits when available)
Phone Number	9724631253
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	450742
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	BAYLOR SCOTT AND WHITE MEDICAL CENTER LAKE POINTE
	Legal business name of hospital where individual professional provides service 1
Hospital Affiliation CCN 2	450352
	Medicare CCN of hospital where individual professional provides service 2
Hospital Affiliation LBN 2	HUNT REGIONAL MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 2
Professional Accepts Medicare Assignment	Y