Individual
LAURIE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
28050 GRAND RIVER AVE, ER DEPARTMENT, FARMINGTON HILLS, MI 48336-5919
(248) 471-8000
Mailing address
PO BOX 634087, CINCINNATI, OH 45263-0001
(800) 540-8739
(616) 975-9827
Taxonomy
Speciality
Code
Description
License number
State
207PE0004X
Emergency Medical Services (Emergency Medicine) Physician
Primary
LW010385
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
114570889
—
MI
Enumeration date
06/09/2006
Last updated
11/28/2016
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