Basic Information
| Provider Information | |||||||||
| NPI: | 1386619831 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27340 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850617340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029439200 | ||||||||
| FaxNumber: | 6022163000 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 W THOMAS RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 11/30/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | 22535 | AZ | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | 22535 | AZ | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | AZ0835370 | 01 | AZ | BCBSAZ | OTHER | XPY191790 | 01 | AZ | MEDI-CAL MEDICAID | OTHER | 1Z7046 | 01 | AZ | HEALTH NET OF AZ | OTHER | 404369 | 05 | AZ | MEDICAID |