MEDICARE: STEVEN B WALLACH D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	2113	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	AZ0064670	OTHER	AZ	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1114027117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEVEN B WALLACH D.O.

Provider Business Mailing Address
First Line	:	3005 W INA RD
Second Line	:	SUITE 123
City	:	TUCSON
State	:	AZ
Zip	:	85741-2107
Country	:	US
Telephone Number	:	520-575-9110
Fax Number	:	520-575-8033

Provider Business Practice Location Address
First Line	:	3005 W INA RD
Second Line	:	SUITE 123
City	:	TUCSON
State	:	AZ
Zip	:	85741-2107
Country	:	US
Telephone Number	:	520-575-9110
Fax Number	:	520-575-8033

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	07/08/2007

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Directions to “ STEVEN B WALLACH D.O.” Practice Location

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