Provider Demographics
NPI:1841261591
Name:WALLACH, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WALLACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CATAMORE BLVD
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914
Mailing Address - Country:US
Mailing Address - Phone:401-432-2520
Mailing Address - Fax:
Practice Address - Street 1:20 CATAMORE BLVD
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914
Practice Address - Country:US
Practice Address - Phone:401-432-2520
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI73292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000001988OtherNHPRI
1600203OtherUNITED HEALTH PLANS
W&I PILGRIMOther240161
3207765OtherHEALTHY START
7000630OtherRI MEDICAL ASSISTANCE
007329OtherTUFTS
7329OtherFEP BLUE CROSS
007329OtherBLUE SHIELD
240161OtherRIH PILGRIM
3207765OtherMASS MEDICAID
004389OtherBLUE CHIP
240161OtherRIH PILGRIM