Basic Information
| Provider Information | |||||||||
| NPI: | 1841422003 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AARON J WALLACE, MD,PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9178 | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728119178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799684273 | ||||||||
| FaxNumber: | 4799681363 | ||||||||
| Practice Location | |||||||||
| Address1: | 628 HOSPITAL DR | ||||||||
| Address2: | SUITE E | ||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726532953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704244710 | ||||||||
| FaxNumber: | 8704244780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2009 | ||||||||
| LastUpdateDate: | 06/24/2010 | ||||||||
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| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | AARON | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8704244710 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 5G172 | 01 | AR | BCBS | OTHER | 179058002 | 05 | AR | MEDICAID |