| Wallace Physician Services LLC | |
|
1577 Goodman Ave Ste A Cincinnati OH 45224-1044 | |
| (513) 403-3762 | |
| (513) 521-6403 |
| Full Name | Wallace Physician Services LLC |
|---|---|
| Speciality | Internal Medicine |
| Location | 1577 Goodman Ave Ste A, Cincinnati, Ohio |
| Authorized Official Name and Position | Waymon L Wallace (PRESIDENT) |
| Authorized Official Contact | 5136749601 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Wallace Physician Services LLC Po Box 40535 Cincinnati OH 45240-0535 Ph: (859) 384-9045 | Wallace Physician Services LLC 1577 Goodman Ave Ste A Cincinnati OH 45224-1044 Ph: (513) 403-3762 |
| NPI Number | 1144527870 |
|---|---|
| Provider Enumeration Date | 02/15/2011 |
| Last Update Date | 07/21/2022 |
| Medicare PECOS PAC ID | 2062695141 |
|---|---|
| Medicare Enrollment ID | O20171024002033 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1144527870 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | 35-076674 (Ohio) | Primary |
| Provider Name | Waymon Leland Wallace |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1841213667 PECOS PAC ID: 7315916335 Enrollment ID: I20040927001175 |
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