Provider Demographics
NPI:1639287212
Name:WALLACE, PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
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 1:801 JOE MANN BLVD STE P-6
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-8900
Mailing Address - Country:US
Mailing Address - Phone:989-791-2455
Mailing Address - Fax:989-791-1392
Practice Address - Street 1:7806 CRESHEIM RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-4003
Practice Address - Country:US
Practice Address - Phone:215-930-6630
Practice Address - Fax:866-404-2729
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD458894207R00000X
CAA68890208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A688900Medicaid
H31622Medicare UPIN
CA00A688900Medicaid