MEDICARE: SIMEON H. WALL, MD A PROFESSIONAL MEDICAL CORP

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	208200000X	Plastic Surgery Physician	02970R	LA

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

General Provider Information

NPI Number	:	1992059968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIMEON H. WALL, MD A PROFESSIONAL MEDICAL CORP

Provider Business Mailing Address
First Line	:	8600 FERN AVE
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-5639
Country	:	US
Telephone Number	:	318-795-0801
Fax Number	:	318-795-9492

Provider Business Practice Location Address
First Line	:	8600 FERN AVE
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-5639
Country	:	US
Telephone Number	:	318-795-0801
Fax Number	:	318-795-9492

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SIMEON HENINGER WALL SR.
Credential	:	M.D.
Telephone Number	:	318-795-0801

Provider Enumeration Date	:	10/30/2012
Last Update Date	:	10/30/2012

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