Individual
ERNEST WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1025 MAINE ST, QUINCY, IL 62301-4038
(217) 222-6550
Mailing address
1025 MAINE ST, QUINCY, IL 62301-4038
(217) 222-6550
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
036113040
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036113040
—
IL
Enumeration date
02/10/2006
Last updated
02/12/2010
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