Provider Demographics
NPI:1629796941
Name:WALLACE VASCULAR, LLC.
Entity Type:Organization
Organization Name:WALLACE VASCULAR, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-201-2399
Mailing Address - Street 1:51 DUTILH RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CRANBERRY TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-4148
Mailing Address - Country:US
Mailing Address - Phone:724-201-2399
Mailing Address - Fax:724-776-3864
Practice Address - Street 1:51 DUTILH RD STE 100
Practice Address - Street 2:
Practice Address - City:CRANBERRY TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:16066-4148
Practice Address - Country:US
Practice Address - Phone:724-201-2399
Practice Address - Fax:724-776-3864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty