Basic Information
| Provider Information | |||||||||
| NPI: | 1649369976 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX: PSYCH | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052496220 | ||||||||
| FaxNumber: | 5852760161 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 OFFICE PARK WAY | ||||||||
| Address2: | |||||||||
| City: | PITTSFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052496220 | ||||||||
| FaxNumber: | 5855865512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 04/05/2011 | ||||||||
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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 | 2084P0800X | 185559 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 185559 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | 185559-1 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | EXCELLUS BCBS | 01 | NY | 2006 | OTHER | PREFERRED CORE | 01 | NY | 102663EW | OTHER | 01685092 | 05 | NY | MEDICAID |