Basic Information
| Provider Information | |||||||||
| NPI: | 1104394329 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SCOTT C. WALLACE MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 112 | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473080112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652840493 | ||||||||
| FaxNumber: | 7652842434 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 ROSS AVE | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922434306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013055959 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2018 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7652840493 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.