Physician Compare National (NPI:1730247149)

HEALTHCARE PROVIDER: ROBERT S WALLACH DO

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

Individual Professional Information
NPI	1730247149
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	5890871057
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20080820000214
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	WALLACH
	Individual professional last name
Provider First Name	ROBERT
	Individual professional first name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	AT STILL UNIVERSITY OF HEALTH SCIENCES, COLLEGE OF OSTEO MED, KIRKSVILLE
	Individual professional's medical school
Graduation Year	2000
	Individual professional's medical school graduation year
Primary Specialty	PHYSICAL MEDICINE AND REHABILITATION
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Line 1 Street Address	555 RIVERGATE
	Group Practice or individual's line 1 address
Line 2 Street Address	SUITE B1 102
	Group Practice or individual's line 2 address
City	DURANGO
	Group Practice or individual's city
State	CO
	Group Practice or individual's state
Zip Code	813017470
	Group Practice or individual's zip code (9 digits when available)

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	060117
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	ANIMAS SURGICAL HOSPITAL, LLC
	Legal business name of hospital where individual professional provides service 1
Hospital Affiliation CCN 2	060013
	Medicare CCN of hospital where individual professional provides service 2
Hospital Affiliation LBN 2	MERCY REGIONAL MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 2
Professional Accepts Medicare Assignment	Y