Provider Demographics
NPI:1417923863
Name:WALLACH, COREY J (MD)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:J
Last Name:WALLACH
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 1:2445 ARMY NAVY DRIVE
Mailing Address - Street 2:THE ANDERSON CLINIC
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22206
Mailing Address - Country:US
Mailing Address - Phone:703-892-6500
Mailing Address - Fax:703-892-1550
Practice Address - Street 1:2445 ARMY NAVY DRIVE
Practice Address - Street 2:THE ANDERSON CLINIC
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22206
Practice Address - Country:US
Practice Address - Phone:703-892-6500
Practice Address - Fax:703-892-1550
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD425770174400000X
CAA95705207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No174400000XOther Service ProvidersSpecialist
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAI27286Medicare UPIN
PA089655E0DMedicare ID - Type Unspecified