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1740219369

NPI Code Detail

MEDICARE: DR. PATRICK JOSEPH WALLACE M.D.

MEDICARE: DR. PATRICK JOSEPH 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	208600000X	Surgery Physician	J7243	TX
2	2086X0206X	Surgical Oncology Physician	J7243	TX
3	2086S0127X	Trauma Surgery Physician	J7243	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00229401	OTHER		MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8S4802	OTHER	TX	BLUE CROSS/BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740219369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PATRICK JOSEPH WALLACE M.D.

Provider Business Mailing Address
First Line	:	2240 GULF FWY S STE 2.100
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-5143
Country	:	US
Telephone Number	:	832-505-1800
Fax Number	:

Provider Business Practice Location Address
First Line	:	2240 GULF FWY S STE 2.100
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-5143
Country	:	US
Telephone Number	:	832-505-1800
Fax Number	:

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

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	11/21/2023

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Directions to “ DR. PATRICK JOSEPH WALLACE M.D.” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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