MEDICARE: ELIOT M WALLACK 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
1	2084N0400X	Neurology Physician	MD431377	PA

General Provider Information

NPI Number	:	1750385449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIOT M WALLACK MD

Provider Business Mailing Address
First Line	:	1840 SOUTH ST
Second Line	:	TUTTLEMAN BUILDING
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-7411
Country	:	US
Telephone Number	:	215-893-6200
Fax Number	:

Provider Business Practice Location Address
First Line	:	1840 SOUTH ST
Second Line	:	TUTTLEMAN BUILDING
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-7411
Country	:	US
Telephone Number	:	215-893-6200
Fax Number	:

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

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	02/10/2016

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