Provider Demographics
NPI:1346284957
Name:WALLACE, GREGORY HALL (DO)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:HALL
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 640220
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45264-0220
Mailing Address - Country:US
Mailing Address - Phone:513-281-8000
Mailing Address - Fax:513-281-5221
Practice Address - Street 1:4623 WESLEY AVE
Practice Address - Street 2:BMF PEDIATRIC CARE SUITE G
Practice Address - City:NORWOOD
Practice Address - State:OH
Practice Address - Zip Code:45212
Practice Address - Country:US
Practice Address - Phone:513-631-3338
Practice Address - Fax:513-631-3385
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008036W208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2442986Medicaid