Provider Demographics
NPI:1790968154
Name:WALLACE, EDWIN RUSH III (MPT)
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:RUSH
Last Name:WALLACE
Suffix:III
Gender:M
Credentials:MPT
Other - Prefix:
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Mailing Address - Street 1:PO BOX 1769
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20118-1769
Mailing Address - Country:US
Mailing Address - Phone:571-370-3686
Mailing Address - Fax:571-370-3687
Practice Address - Street 1:24560 SOUTHPOINT DR STE 250
Practice Address - Street 2:
Practice Address - City:ALDIE
Practice Address - State:VA
Practice Address - Zip Code:20105-3504
Practice Address - Country:US
Practice Address - Phone:571-370-3686
Practice Address - Fax:571-370-3687
Is Sole Proprietor?:No
Enumeration Date:2007-12-07
Last Update Date:2023-09-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA2305005465225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist