Provider Demographics
NPI:1316086291
Name:WALLACE, RYAN C (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:C
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:765-747-3241
Practice Address - Fax:765-281-6567
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2021-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061221A207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00742247OtherRAILROAD MEDICARE
IN000000688369OtherANTHEM BC/BS
IN200802900Medicaid
IN200802900AMedicaid
INP00841092OtherRAILROAD MEDICARE
IN000000626067OtherANTHEM BC/BS
INP00841092OtherRAILROAD MEDICARE
IN261920QMedicare PIN
IN000000626067OtherANTHEM BC/BS
INM400058136Medicare PIN
IN000000688369OtherANTHEM BC/BS
IN203170RRRMedicare PIN