Basic Information
| Provider Information | |||||||||
| NPI: | 1154434488 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 143 LONGWATER DR | ||||||||
| Address2: | |||||||||
| City: | NORWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020611683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818785200 | ||||||||
| FaxNumber: | 7818786750 | ||||||||
| Practice Location | |||||||||
| Address1: | 143 LONGWATER DR | ||||||||
| Address2: | |||||||||
| City: | NORWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020611683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818785200 | ||||||||
| FaxNumber: | 7818786750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 02/09/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 243033 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1154434488 | 01 | TUFTS HEALTH PLAN | OTHER | 1154434488 | 05 | MA | MEDICAID | 7087919 | 01 | MA | AETNA | OTHER | 1154434488 | 01 | MA | TMP | OTHER | 04-2297845 | 01 | UNITED HEALTH CARE | OTHER | 042297845 | 01 | MA | MULTI-PLAN | OTHER | 1154434488 | 01 | MA | NEIGHBORHOOD HEALTH PLAN | OTHER | 1154434488 | 01 | FALLON HEALTH CARE | OTHER | SS0165 | 01 | MA | BCBSMA | OTHER | 042297845 | 01 | HCVM | OTHER | 042297845 | 01 | TRICARE | OTHER | 3748610 | 01 | MA | CIGNA | OTHER | AA387771 | 01 | MA | HARVARD PILGRIM | OTHER |