Physician Compare National (NPI:1639174105)

HEALTHCARE PROVIDER: WENDELL E. WALL 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	1639174105
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	4688755523
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20080116000559
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	WALL
	Individual professional last name
Provider First Name	WENDELL
	Individual professional first name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	UNIVERSITY OF TEXAS MEDICAL BRANCH AT GALVESTON
	Individual professional's medical school
Graduation Year	1992
	Individual professional's medical school graduation year
Primary Specialty	INTERNAL MEDICINE
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Line 1 Street Address	1801 FAIRFIELD AVE
	Group Practice or individual's line 1 address
Line 2 Street Address	SUITE 200
	Group Practice or individual's line 2 address
City	SHREVEPORT
	Group Practice or individual's city
State	LA
	Group Practice or individual's state
Zip Code	711014460
	Group Practice or individual's zip code (9 digits when available)

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	190041
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	CHRISTUS HEALTH SHREVEPORT - BOSSIER
	Legal business name of hospital where individual professional provides service 1
Hospital Affiliation CCN 2	190111
	Medicare CCN of hospital where individual professional provides service 2
Hospital Affiliation LBN 2	WILLIS KNIGHTON MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 2
Professional Accepts Medicare Assignment	Y