MEDICARE: SYBILLE WALLACE 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	174400000X	Specialist
2	2084P0804X	Child & Adolescent Psychiatry Physician	122478	NY
3	208000000X	Pediatrics Physician	122478	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	122478	OTHER	NY	LICENSE

General Provider Information

NPI Number	:	1235106006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SYBILLE WALLACE M.D.

Provider Business Mailing Address
First Line	:	5 EAST 98TH STREET
Second Line	:	BOX 1206
City	:	NEW YORK
State	:	NY
Zip	:	10029-6574
Country	:	US
Telephone Number	:	212-241-7163
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 EAST 98TH STREET
Second Line	:	BOX 1206
City	:	NEW YORK
State	:	NY
Zip	:	10029-6574
Country	:	US
Telephone Number	:	212-241-7163
Fax Number	:

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

Provider Enumeration Date	:	03/01/2006
Last Update Date	:	03/26/2013

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