Provider Demographics
NPI:1154422343
Name:WALLACE MEDICAL GROUP
Entity type:Organization
Organization Name:WALLACE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-652-8460
Mailing Address - Street 1:8920 WILSHIRE BLVD
Mailing Address - Street 2:#327
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2003
Mailing Address - Country:US
Mailing Address - Phone:310-652-8460
Mailing Address - Fax:310-652-8499
Practice Address - Street 1:8920 WILSHIRE BLVD
Practice Address - Street 2:#327
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2007
Practice Address - Country:US
Practice Address - Phone:310-652-8460
Practice Address - Fax:310-652-8499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49918207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0062021Medicaid
CAWA49118CMedicare ID - Type UnspecifiedMEDICARE NUMBER
CAGR0062021Medicaid