Basic Information
| Provider Information | |||||||||
| NPI: | 1841261591 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 CATAMORE BLVD | ||||||||
| Address2: | |||||||||
| City: | EAST PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014322520 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20 CATAMORE BLVD | ||||||||
| Address2: | |||||||||
| City: | EAST PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014322520 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 7329 | RI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000000001988 | 01 | NHPRI | OTHER | 1600203 | 01 | UNITED HEALTH PLANS | OTHER | W&I PILGRIM | 01 | 240161 | OTHER | 3207765 | 01 | HEALTHY START | OTHER | 7000630 | 01 | RI MEDICAL ASSISTANCE | OTHER | 007329 | 01 | TUFTS | OTHER | 7329 | 01 | FEP BLUE CROSS | OTHER | 007329 | 01 | BLUE SHIELD | OTHER | 240161 | 01 | RIH PILGRIM | OTHER | 3207765 | 01 | MASS MEDICAID | OTHER | 004389 | 01 | BLUE CHIP | OTHER |