Provider Demographics
NPI:1801117585
Name:WALLACE, ADAM N (MD)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:N
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2301 N LAKE DR STE 1104
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-4508
Mailing Address - Country:US
Mailing Address - Phone:414-585-3223
Mailing Address - Fax:414-585-3229
Practice Address - Street 1:8201 EAST RIVERSIDE BOULEVARD
Practice Address - Street 2:MERCY HEALTH JAVON BAE HOSPITAL
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-2300
Practice Address - Country:US
Practice Address - Phone:815-971-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI70505-202085N0700X
MN618982085N0700X
CODR.00689062085R0202X
MO20150131142085R0202X
NY3199832085R0202X
IL036.1488222085R0202X, 2085N0700X
WI705052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200021565Medicaid