Provider Demographics
NPI:1568652485
Name:JAMES E. WALLACE, JR, M.D., LLC
Entity Type:Organization
Organization Name:JAMES E. WALLACE, JR, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:DEWITT
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:318-561-9600
Mailing Address - Street 1:1135 EXPRESSWAY DR
Mailing Address - Street 2:SUITE 200 A
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-6698
Mailing Address - Country:US
Mailing Address - Phone:318-561-9600
Mailing Address - Fax:318-561-0228
Practice Address - Street 1:1135 EXPRESSWAY DR
Practice Address - Street 2:SUITE 200 A
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-6698
Practice Address - Country:US
Practice Address - Phone:318-561-9600
Practice Address - Fax:318-561-0228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.200134207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1627950Medicaid
LA5BC71Medicare PIN
LAH11073Medicare UPIN