Individual
RYAN C WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2401 W UNIVERSITY AVE, MUNCIE, IN 47303-3428
(765) 747-3241
(765) 281-6567
Mailing address
250 N SHADELAND AVE, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
01061221A
IN
207Q00000X
Family Medicine Physician
01061221A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000626067
ANTHEM BC/BS
IN
01
—
000000688369
ANTHEM BC/BS
IN
05
—
200802900
—
IN
05
—
200802900A
—
IN
01
—
P00742247
RAILROAD MEDICARE
IN
01
—
P00841092
RAILROAD MEDICARE
IN
Enumeration date
02/06/2007
Last updated
03/06/2021
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