Provider Demographics
NPI:1770823213
Name:WALLACE SPORTS MEDICINE PA
Entity Type:Organization
Organization Name:WALLACE SPORTS MEDICINE PA
Other - Org Name:WALLACE SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-722-4830
Mailing Address - Street 1:8440 WALNUT HILL LN
Mailing Address - Street 2:SUITE 120
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-3833
Mailing Address - Country:US
Mailing Address - Phone:214-506-2610
Mailing Address - Fax:
Practice Address - Street 1:2313 RIDGE RD STE 105B
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-5141
Practice Address - Country:US
Practice Address - Phone:972-722-4830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-20
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty