Wallace, Lance T

Wallace, Lance T is an individual health care provider with primary practice located at 20939 S Cicero Ave , Matteson IL 60443-1620. He recently has only one registered license in Allopathic & Osteopathic Physicians / Internal Medicine, which is considered as his primary health care specialty. Wallace, Lance T can be contacted via phone (708) 709-9375.

Contact Information

Primary practice address
20939 S Cicero Ave Matteson IL 60443-1620
Phone: (708) 709-9375
Fax: (708) 709-6353
Website:
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Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Internal Medicine 207R00000X 036085478 Illinois

Profile Details

NPI number 1538100128
LBN Legal business name Wallace, Lance T
Credentials Doctor of Medicine (MD)
Entity Individual
Sole proprietor 1 No
Enumeration date Jun 8th, 2006
Last updated Mar 15th, 2021 - about 4 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1538100128 NPPES
Illinois Other IL5686032 MEDICARE PTAN
Illinois MEDICAID 036085478 MEDICARE PTAN

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