Individual
LANCE T WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
20939 S CICERO AVE, MATTESON, IL 60443-1620
(708) 709-9375
(708) 709-6353
Mailing address
35318 EAGLE WAY, CHICAGO, IL 60678-1353
(317) 865-8988
(317) 859-8590
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
036085478
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036085478
—
IL
01
—
IL5686032
MEDICARE PTAN
IL
Enumeration date
06/08/2006
Last updated
03/15/2021
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