Provider Demographics
NPI:1144527870
Name:WALLACE PHYSICIAN SERVICES LLC
Entity type:Organization
Organization Name:WALLACE PHYSICIAN SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYMON
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-674-9601
Mailing Address - Street 1:PO BOX 40535
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45240-0535
Mailing Address - Country:US
Mailing Address - Phone:859-384-9045
Mailing Address - Fax:859-212-0949
Practice Address - Street 1:1577 GOODMAN AVE STE A
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45224-1044
Practice Address - Country:US
Practice Address - Phone:513-403-3762
Practice Address - Fax:513-521-6403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-076674207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty