Individual
JOHN R WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1414 W FAIR AVE, SUITE 111, MARQUETTE, MI 49855-2675
(906) 225-7601
(906) 225-7453
Mailing address
4602 DEPT, CAROL STREAM, IL 60122-0021
(906) 225-7601
(906) 225-7453
Taxonomy
Speciality
Code
Description
License number
State
207RI0200X
Infectious Disease Physician
Primary
4301075195
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
110189987
RAILROAD MEDICARE
MI
05
—
4138271
—
MI
01
—
JW075195
BCBSM
MI
Enumeration date
09/12/2005
Last updated
04/22/2009
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