MEDICARE: WALLACE C GAUNTNER M.D.

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	207RN0300X	Nephrology Physician	35068280	OH
2	207RN0300X	Nephrology Physician	MD019281E	PA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	110025252	OTHER		RAILROAD MEDICARE

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114929403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALLACE C GAUNTNER M.D.

Provider Business Mailing Address
First Line	:	824 CALIFORNIA AVE
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15202-2706
Country	:	US
Telephone Number	:	412-766-3232
Fax Number	:	412-766-4320

Provider Business Practice Location Address
First Line	:	824 CALIFORNIA AVE
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15202-2706
Country	:	US
Telephone Number	:	412-766-3232
Fax Number	:	412-766-4320

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

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	01/15/2020

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Directions to “ WALLACE C GAUNTNER M.D.” Practice Location

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