Provider Demographics
NPI:1437114139
Name:WALLACE, DREW A (MS,PT)
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MS,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 BETHLEHEM PIKE
Mailing Address - Street 2:
Mailing Address - City:FLOURTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19031-2026
Mailing Address - Country:US
Mailing Address - Phone:215-233-9677
Mailing Address - Fax:215-233-9498
Practice Address - Street 1:1600 BETHLEHEM PIKE
Practice Address - Street 2:
Practice Address - City:FLOURTOWN
Practice Address - State:PA
Practice Address - Zip Code:19031-2026
Practice Address - Country:US
Practice Address - Phone:215-233-9677
Practice Address - Fax:215-233-9498
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA007969L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA045909Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL PROVI