Basic Information
| Provider Information | |||||||||
| NPI: | 1871592329 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3515 MASSILLON RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | UNIONTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446857854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308999350 | ||||||||
| FaxNumber: | 3306341329 | ||||||||
| Practice Location | |||||||||
| Address1: | 4444 ARLINGTON RD | ||||||||
| Address2: | |||||||||
| City: | UNIONTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446859508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308966111 | ||||||||
| FaxNumber: | 3306341329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35073269 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1841239274 | 01 | OH | PARTNERS PHYSICIAN GROUP TYPE 2 NPI # | OTHER | 2166310 | 05 | OH | MEDICAID | 2551671 | 01 | OH | PARTNERS PHYSICIAN GROUP MEDICAID GROUP # | OTHER | 9338635 | 01 | OH | PARTNERS PHYSICIAN GROUP MEDICARE GROUP # | OTHER |