Individual
RAYMOND B WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
111 E WISCONSIN AVE, SUITE 2000, MILWAUKEE, WI 53202-4815
(414) 290-6720
(414) 290-6755
Mailing address
1700 CORAL DR, STE A, WAUKESHA, WI 53186-1483
(414) 290-6720
(414) 290-6755
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
44478-021
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
43500600
—
WI
01
—
930122235
MEDICARE RAILROAD
WI
Enumeration date
07/06/2006
Last updated
09/26/2016
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