MEDICARE: WALLACE BRUCE OBENSHAIN CECILTON FAMILY PRACTICE

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	D0035779	MD

General Provider Information

NPI Number	:	1134261217
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALLACE BRUCE OBENSHAIN CECILTON FAMILY PRACTICE

Provider Business Mailing Address
First Line	:	PO BOX 190
Second Line	:
City	:	ELKTON
State	:	MD
Zip	:	21922-0190
Country	:	US
Telephone Number	:	410-398-4679
Fax Number	:

Provider Business Practice Location Address
First Line	:	251 BOHEMIA AVE
Second Line	:
City	:	CECILTON
State	:	MD
Zip	:	21913
Country	:	US
Telephone Number	:	410-275-8157
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	LISA FIELDS
Credential	:
Telephone Number	:	410-398-4679

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	06/12/2008

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