Provider Demographics
NPI:1255499638
Name:JANET N. WALLACE, MD, INC.
Entity Type:Organization
Organization Name:JANET N. WALLACE, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:N
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-697-0554
Mailing Address - Street 1:2703 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702-1303
Mailing Address - Country:US
Mailing Address - Phone:304-697-0554
Mailing Address - Fax:304-697-0555
Practice Address - Street 1:2703 3RD AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1303
Practice Address - Country:US
Practice Address - Phone:304-697-0554
Practice Address - Fax:304-697-0555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0046053000Medicaid
WV0046053000Medicaid
WV9276221Medicare PIN