Provider Demographics
NPI:1548360514
Name:WALLICK, PETER GLENN (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:GLENN
Last Name:WALLICK
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 1:2000 SCOTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-1452
Mailing Address - Country:US
Mailing Address - Phone:717-263-7788
Mailing Address - Fax:717-263-7609
Practice Address - Street 1:2000 SCOTLAND AVE
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-1452
Practice Address - Country:US
Practice Address - Phone:717-263-7788
Practice Address - Fax:717-263-7609
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA044-299-L208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001253180 0003Medicaid
PA001253180 0002Medicaid
PA678804OtherBLUE SHIELD
PA347968700OtherDEPT. OF LABOR (WC)
PAPO00756OtherCHAMPUS-TRICARE
PA01041201OtherBLUE CROSS
PA01041201OtherBLUE CROSS
PA001253180 0003Medicaid
PA347968700OtherDEPT. OF LABOR (WC)