Provider Demographics
NPI:1659488690
Name:WALLACE, BRIAN KEN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KEN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:414-649-6732
Mailing Address - Fax:414-649-5840
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY
Practice Address - Street 2:#250
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215
Practice Address - Country:US
Practice Address - Phone:414-649-6732
Practice Address - Fax:414-649-5840
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI27108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30848800Medicaid
BW0897655OtherDEA NUMBER
BW0897655OtherDEA NUMBER