Provider Demographics
NPI:1801982475
Name:WALLACE, MICHAEL H (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:H
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:788 8TH AVENUE SE
Mailing Address - Street 2:SUITE 204, MERCY EMPLOYEE HEALTH CENTER
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52401
Mailing Address - Country:US
Mailing Address - Phone:319-398-6342
Mailing Address - Fax:319-558-0330
Practice Address - Street 1:788 8TH AVENUE SE
Practice Address - Street 2:SUITE 204
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52401
Practice Address - Country:US
Practice Address - Phone:319-398-6342
Practice Address - Fax:319-558-0330
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-06-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IA37120207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
546138Medicare ID - Type Unspecified
I14188Medicare UPIN