MEDICARE: WALLACE MANN MD PA

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	K6771	TX

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

General Provider Information

NPI Number	:	1437352770
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALLACE MANN MD PA

Provider Business Mailing Address
First Line	:	202 S MCGEE ST
Second Line	:
City	:	BORGER
State	:	TX
Zip	:	79007-4022
Country	:	US
Telephone Number	:	806-273-7118
Fax Number	:	806-274-6070

Provider Business Practice Location Address
First Line	:	202 S MCGEE ST
Second Line	:
City	:	BORGER
State	:	TX
Zip	:	79007-4022
Country	:	US
Telephone Number	:	806-273-7118
Fax Number	:	806-274-6070

Authorized Official
Title or Position	:	OWNER CEO
Name	:	MR. WALLACE MANN
Credential	:	MD
Telephone Number	:	806-273-7118

Provider Enumeration Date	:	06/06/2007
Last Update Date	:	05/13/2024

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