Basic Information
| Provider Information | |||||||||
| NPI: | 1326043373 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLEN | ||||||||
| FirstName: | NEIL | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376620009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238447000 | ||||||||
| FaxNumber: | 4238447007 | ||||||||
| Practice Location | |||||||||
| Address1: | 933 HIGHWAY 126 | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376203310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238447000 | ||||||||
| FaxNumber: | 4238447007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 09/24/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/18/2006 | ||||||||
| NPIReactivationDate: | 03/24/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X | MD0000017754 | TN | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy |
ID Information
| ID | Type | State | Issuer | Description | 1326043373 | 05 | VA | MEDICAID | 006002188 | 05 | VA | MEDICAID | 1510634 | 05 | TN | MEDICAID | 3032572 | 05 | TN | MEDICAID |