| Doctor Name: | DIANE S WALLACE |
| NPI Number: | 1194764647 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MD |
| License Number: | 01061919A |
| Business Practice Address: | 301 W Homer St Michigan City, IN - 463604358 |
| Business Phone Number: | 2198798511 |
| Business Fax Number: | |
| Mailing Address: | 2000 Green Rd, Suite 300 ANN ARBOR |
| State: | MI |
| Postal Code: | 481051598 |
| Phone Number: | 7349953764 |
| Fax Number: | |
| NPI Enumeration Date: | 06/06/2006 |
| NPI Last Update Date: | 11/11/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 207PE0004X |
| License Number: | 01061919A |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IN |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | Emergency Medicine |
| Taxonomy Specialization: | Emergency Medical Services |
| Taxonomy Definition: | An emergency medicine physician who specializes in non-hospital based emergency medical services (e.g., disaster site, accident scene, transport vehicle, etc.) to provide pre-hospital assessment, treatment, and transport patients. |