Basic Information
| Provider Information | |||||||||
| NPI: | 1225122567 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLIS | ||||||||
| FirstName: | JEROLD | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | CB 8131 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143627200 | ||||||||
| FaxNumber: | 3147474189 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 S KINGSHIGHWAY BLVD | ||||||||
| Address2: | DEPT RADIOLOGY | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143627200 | ||||||||
| FaxNumber: | 3147474189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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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 | 207U00000X | R9F90 | MO | Y | Allopathic & Osteopathic Physicians | Nuclear Medicine |
ID Information
| ID | Type | State | Issuer | Description | 209730209 | 05 | MO | MEDICAID |