Provider Demographics
NPI:1144458969
Name:WALLACE, SARAH J (DO)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:J
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:J
Other - Last Name:DEBIAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:4100 EMBASSY DR SE STE 400
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2416
Mailing Address - Country:US
Mailing Address - Phone:616-975-1845
Mailing Address - Fax:
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-1680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315052367207L00000X
MI5101018343207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1144458969Medicaid
MI1144458969Medicaid