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NPI Code Detail

MEDICARE: MRS. MARY MELANIE WALLER MD

MEDICARE: MRS. MARY MELANIE WALLER MD
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
1208800000XUrology Physician036119328IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1225024615
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. MARY MELANIE WALLER MD
Provider Business Mailing Address
First Line : PO BOX 97
Second Line :
City : OLNEY
State : IL
Zip : 62450-0097
Country : US
Telephone Number : 618-395-7340
Fax Number :
Provider Business Practice Location Address
First Line : 1200 N EAST ST
Second Line :
City : OLNEY
State : IL
Zip : 62450-2432
Country : US
Telephone Number : 618-395-5222
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/21/2005
Last Update Date : 10/05/2009

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