Basic Information
| Provider Information | |||||||||
| NPI: | 1770504888 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | HAROLD | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 291 MOODY ST | ||||||||
| Address2: | PER SE TECHNOLOGIES | ||||||||
| City: | LUDLOW | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010561246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008666663 | ||||||||
| FaxNumber: | 8884131065 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 COLCHESTER AVE | ||||||||
| Address2: | FLETCHER ALLEN HEALTH CARE DEPT. OF RADIATION ONCOLOGY | ||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028473506 | ||||||||
| FaxNumber: | 8028472386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2085R0001X | 042-0009975 | VT | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | OVN2161 | 05 | VT | MEDICAID |