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NPI Code Detail

MEDICARE: DR. MAXWELL WALLACE M.D.

MEDICARE: DR. MAXWELL 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
12084N0402XNeurology with Special Qualifications in Child Neurology Physician2022027207MO

General Provider Information

NPI Number : 1588195267
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MAXWELL WALLACE M.D.
Provider Business Mailing Address
First Line : 1465 S GRAND BLVD
Second Line : RM 2717
City : SAINT LOUIS
State : MO
Zip : 63104-1003
Country : US
Telephone Number : 314-577-5634
Fax Number : 314-577-5616
Provider Business Practice Location Address
First Line : 1465 S GRAND BLVD
Second Line : RM 2717
City : SAINT LOUIS
State : MO
Zip : 63104-1003
Country : US
Telephone Number : 314-577-5634
Fax Number : 314-577-5616
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/23/2017
Last Update Date : 08/22/2022

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