Basic Information
| Provider Information | |||||||||
| NPI: | 1508880303 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24701 EUCLID AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441171714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163836616 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168447330 | ||||||||
| FaxNumber: | 2168443781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 08/19/2010 | ||||||||
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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 | 207L00000X | 34-005216 | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LA0401X | 34-005216 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | Addiction Medicine | 207LC0200X | 34-005216 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207LH0002X | 34-005216 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | Hospice and Palliative Medicine | 207LP2900X | 34-005216 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP3000X | 34-005216 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 364105 | 01 | OH | WELLCARE MEDICAID | OTHER | 5792078 | 01 | OH | AETNA | OTHER | 0856622 | 05 | OH | MEDICAID | 50060854 | 01 | OH | RAILROAD MEDICARE | OTHER | P00412647 | 01 | OH | MEDICARE RAILROAD | OTHER | 000000221259 | 01 | OH | UNISON | OTHER | 0583328 | 01 | OH | BCMH | OTHER | 000000516017 | 01 | OH | ANTHEM | OTHER | 751023 | 01 | OH | BUCKEYE MEDICAID | OTHER |