Provider Demographics
NPI:1518124627
Name:WALLACE, BRIAN SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:SCOTT
Last Name:WALLACE
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:PO BOX 1754
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18105-1754
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:1200 S CEDAR CREST BLVD
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6202
Practice Address - Country:US
Practice Address - Phone:484-862-3232
Practice Address - Fax:484-862-3250
Is Sole Proprietor?:No
Enumeration Date:2008-05-18
Last Update Date:2014-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036120375207P00000X
PAMD453343207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine