Basic Information
| Provider Information | |||||||||
| NPI: | 1659323574 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLIS | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1919 S HIGHLAND AVE | ||||||||
| Address2: | SUITE B202 ATTN JAN LEWIS | ||||||||
| City: | LOMBARD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601486153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302681102 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3825 HIGHLAND AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307194799 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 11/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 036061857 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 036061857 | 05 | IL | MEDICAID | 060043700 | 01 | RAILROAD MEDICARE | OTHER |