MEDICARE: DR. RICHARD A WALL 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	207Q00000X	Family Medicine Physician	10250	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	080088906	OTHER	AZ	RAILROAD MEDICARE

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	86080015085260A099	OTHER	AZ	TRIWEST
4	86080015085259A529	OTHER	AZ	TRIWEST

General Provider Information

NPI Number	:	1811971393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD A WALL M.D.

Provider Business Mailing Address
First Line	:	2500 W UTOPIA RD
Second Line	:	STE. 100
City	:	PHOENIX
State	:	AZ
Zip	:	85027-4171
Country	:	US
Telephone Number	:	623-434-6200
Fax Number	:	623-434-6164

Provider Business Practice Location Address
First Line	:	19841 N 27TH AVE
Second Line	:	STE. 101
City	:	PHOENIX
State	:	AZ
Zip	:	85027-4003
Country	:	US
Telephone Number	:	602-942-8512
Fax Number	:	602-942-1075

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

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	09/27/2013

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Directions to “ DR. RICHARD A WALL M.D.” Practice Location

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