Provider Demographics
NPI:1528027950
Name:WALLISCH, FREDRICK H (MD)
Entity Type:Individual
Prefix:
First Name:FREDRICK
Middle Name:H
Last Name:WALLISCH
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 3407
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47733-3407
Mailing Address - Country:US
Mailing Address - Phone:812-450-3363
Mailing Address - Fax:812-450-3071
Practice Address - Street 1:515 READ ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1739
Practice Address - Country:US
Practice Address - Phone:812-450-3363
Practice Address - Fax:812-450-3071
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059213A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00315732OtherRR MEDICARE
IN200042820Medicaid
IN870350RMedicare PIN
IN257900RMedicare PIN
G11884Medicare UPIN
IN639880HMedicare ID - Type UnspecifiedREAD STREET LOCATION
IN639880HMedicare ID - Type UnspecifiedREAD STREET LOCATION
IN200042820Medicaid
IN000000337161OtherBCBS
INP00315732OtherRR MEDICARE
IN131250JJMedicare ID - Type UnspecifiedMEC - LAWNDALE LOCATION
IN870350RMedicare PIN