Provider Demographics
NPI:1669687307
Name:WALLACE, JAMES A
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 HARVESTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1443
Practice Address - Country:US
Practice Address - Phone:888-824-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113259207RX0202X
IL036-113259207RX0202X, 207RH0003X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL437901OtherMEDICARE GROUP PTAN
ILCA8459OtherR R MEDICARE GROUP
ILP00634373OtherR R MEDICARE INDIVIDUAL
INCE1551OtherRR MEDICARE GROUP
IN200898350Medicaid
IN626820OtherMEDICARE GROUP PTAN
IL036113259Medicaid
ILK51567Medicare UPIN
IN200898350Medicaid
ILP00634373OtherR R MEDICARE INDIVIDUAL