MEDICARE: JOEL J WALLACK 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	2084P0800X	Psychiatry Physician	128307	NY

General Provider Information

NPI Number	:	1881746360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOEL J WALLACK M.D.

Provider Business Mailing Address
First Line	:	222 E 19TH ST
Second Line	:	1D
City	:	NEW YORK
State	:	NY
Zip	:	10003-2607
Country	:	US
Telephone Number	:	212-995-7200
Fax Number	:	212-979-3544

Provider Business Practice Location Address
First Line	:	222 E 19TH ST
Second Line	:	1D
City	:	NEW YORK
State	:	NY
Zip	:	10003-2607
Country	:	US
Telephone Number	:	212-995-7200
Fax Number	:	212-979-3544

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

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	07/08/2007

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