Individual
DONALD R. WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
5114 N GLEN PARK PLACE RD, PEORIA, IL 61614-4686
(309) 683-6600
Mailing address
5114 N GLEN PARK PLACE RD, PEORIA, IL 61614-4686
(309) 683-6600
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
036-077680
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036077680
—
IL
01
—
800810
MEDICARE GROUP NO.
—
01
—
809840
MEDICARE GROUP PTAN
IL
01
—
809840034
MEDICARE INDIVIDUAL PTAN
IL
Enumeration date
08/14/2006
Last updated
07/29/2010
About Stedi
Stedi is the only programmable healthcare clearinghouse. You can use Stedi's APIs to process eligibility checks, claims, remits, and more.
Contact us