Provider Demographics
NPI:1841422003
Name:AARON J WALLACE, MD,PLLC
Entity Type:Organization
Organization Name:AARON J WALLACE, MD,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-424-4710
Mailing Address - Street 1:PO BOX 9178
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9178
Mailing Address - Country:US
Mailing Address - Phone:479-968-4273
Mailing Address - Fax:479-968-1363
Practice Address - Street 1:628 HOSPITAL DR
Practice Address - Street 2:SUITE E
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2953
Practice Address - Country:US
Practice Address - Phone:870-424-4710
Practice Address - Fax:870-424-4780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5G172OtherBCBS
AR179058002Medicaid
AR179058002Medicaid
AR5G172OtherBCBS