Basic Information
| Provider Information | |||||||||
| NPI: | 1457430019 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WALL MEDICAL INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 307 | ||||||||
| Address2: | |||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840110307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012946907 | ||||||||
| FaxNumber: | 8012946917 | ||||||||
| Practice Location | |||||||||
| Address1: | 8074 S 1300 E | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840940743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015656500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 11/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | WALL | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8012946907 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 180274-1205 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.