Provider Demographics
NPI:1538140835
Name:WALLACE, ELISE F (MD)
Entity Type:Individual
Prefix:DR
First Name:ELISE
Middle Name:F
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:DIANE
Other - Last Name:FISCHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1701 SOUTH BLVD E
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-6122
Mailing Address - Country:US
Mailing Address - Phone:248-997-5805
Mailing Address - Fax:248-997-5811
Practice Address - Street 1:1701 SOUTH BLVD E
Practice Address - Street 2:SUITE 200
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-6122
Practice Address - Country:US
Practice Address - Phone:248-997-5805
Practice Address - Fax:248-997-5811
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077878207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OM97940-006Medicare ID - Type Unspecified
I38141Medicare UPIN