MEDICARE: WALLACE R HODGES 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	207R00000X	Internal Medicine Physician	MD00015517	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110022931	OTHER	WA	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	78926	OTHER	WA	LE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841288016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALLACE R HODGES MD

Provider Business Mailing Address
First Line	:	901 BOREN AVE
Second Line	:	STE 615
City	:	SEATTLE
State	:	WA
Zip	:	98104-3595
Country	:	US
Telephone Number	:	206-467-1457
Fax Number	:	206-467-1347

Provider Business Practice Location Address
First Line	:	901 BOREN AVE
Second Line	:	STE 615
City	:	SEATTLE
State	:	WA
Zip	:	98104-3595
Country	:	US
Telephone Number	:	206-467-1457
Fax Number	:	206-467-1347

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

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	03/25/2014

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