Provider Demographics
NPI:1104394329
Name:SCOTT C. WALLACE MD INC
Entity Type:Organization
Organization Name:SCOTT C. WALLACE MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:C
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-284-0493
Mailing Address - Street 1:PO BOX 112
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47308-0112
Mailing Address - Country:US
Mailing Address - Phone:765-284-0493
Mailing Address - Fax:765-284-2434
Practice Address - Street 1:1415 ROSS AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4306
Practice Address - Country:US
Practice Address - Phone:301-305-5959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-06
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric AnesthesiologyGroup - Multi-Specialty