Individual
DR. MAXWELL WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1465 S GRAND BLVD, RM 2717, SAINT LOUIS, MO 63104-1003
(314) 577-5634
(314) 577-5616
Mailing address
1465 S GRAND BLVD, RM 2717, SAINT LOUIS, MO 63104-1003
(314) 577-5634
(314) 577-5616
Taxonomy
Speciality
Code
Description
License number
State
2084N0402X
Neurology with Special Qualifications in Child Neurology Physician
Primary
2022027207
MO
Other
Enumeration date
03/23/2017
Last updated
08/22/2022
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