MEDICARE: STEPHEN A. WALLACE, M.D., P.C.

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	207LP2900X	Pain Medicine (Anesthesiology) Physician	13856	AZ

General Provider Information

NPI Number	:	1952638660
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STEPHEN A. WALLACE, M.D., P.C.

Provider Business Mailing Address
First Line	:	2741 S 8TH AVE
Second Line	:	SUITE C
City	:	YUMA
State	:	AZ
Zip	:	85364-7154
Country	:	US
Telephone Number	:	928-726-0985
Fax Number	:	928-726-9395

Provider Business Practice Location Address
First Line	:	2741 S 8TH AVE
Second Line	:	SUITE C
City	:	YUMA
State	:	AZ
Zip	:	85364-7154
Country	:	US
Telephone Number	:	928-726-0985
Fax Number	:	928-726-9395

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	BECKY L WALLACE
Credential	:
Telephone Number	:	928-726-0985

Provider Enumeration Date	:	11/17/2009
Last Update Date	:	11/17/2009

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