Provider Demographics
NPI:1730177544
Name:WALLACE W SHERRITT DO INC
Entity type:Organization
Organization Name:WALLACE W SHERRITT DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHERRITT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:219-462-5750
Mailing Address - Street 1:9136 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321
Mailing Address - Country:US
Mailing Address - Phone:219-462-5750
Mailing Address - Fax:
Practice Address - Street 1:1551 STURDY RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383
Practice Address - Country:US
Practice Address - Phone:219-462-5750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50002122A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN653210Medicare ID - Type Unspecified