Active NPI
Mikaila Wallace, DO
- Family Medicine Physician
- Maryville, MO
National Provider Identifier
1023687217
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 2024030678
- Practice address
- 2016 S Main St
Maryville, MO 64468-2655 - Phone
- (660) 562-2525
- Fax
- (660) 562-7996
- NPI assigned
- Jun 22, 2021
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 2024030678 | MO | Primary |
| Family Medicine Physician | 207Q00000X | TEP9082 | NE |
Addresses
Primary practice location
2016 S Main St
Maryville, MO 64468-2655
Mailing address
2016 S Main St
Maryville, MO 64468-2655
Phone (660) 562-2525
Other practice location 1
4600 Valley Rd Ste 200
Lincoln, NE 68510-4882
Phone (402) 327-6921
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 200147246 | Medicaid | MO | |
| 470553011-00 | Medicaid | NE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MO
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
Care Compare profile
Medicare Care Compare- Specialty
- Family Practice
- Education
- At Still University of Health Sciences, College of Osteo Med, Kirksville, 2024
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- SSM Regional Health Services
Practice addresses (Care Compare)
2016 S Main St
Maryville, MO 64468-2655
Phone (660) 562-2525
Hospital & facility affiliations
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Osteopathy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2024030678 | MO | MD | Family Medicine Physician |
| TEP9082 | NE | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Mosaic Medical Center - Maryville | Current | Accepting new patients | |
| Mosaic Medical Center - Maryville | Family Medicine | Current | Accepting new patients |
| Mosaic Medical Center - Maryville | Past | Accepting new patients |
Locations
2016 S Main St
Maryville, MO 64468
Phone (660) 562-2525
114 E South Hills Dr
Maryville, MO 64468
Phone (660) 562-2525
Networks
- devoted network organization-2b183dd2-4e80-4977-80a6-4fdf0df4361d
- IA HMO
- IA HMO C-SNP
Organizations & group practices 3
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Psychiatric Hospital Unit
- Maryville, MO
- NPI 1477027803
-
- Rural Health Clinic/Center
- Maryville, MO
- NPI 1821562265
Hospital & facility affiliations 5
Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.
-
- Home Health Agency
- Saint Joseph, MO
- NPI 1003916198
-
- General Acute Care Hospital
- Saint Joseph, MO
- NPI 1437259694
-
- Community Based Hospice Care Agency
- Saint Joseph, MO
- NPI 1912007006
-
- Critical Access Hospital
- Maryville, MO
- NPI 1265906663
-
- Critical Access Hospital
- Albany, MO
- NPI 1306893268
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1624320000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1747008000000",
"number": "1023687217",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2016 S MAIN ST",
"city": "MARYVILLE",
"state": "MO",
"postal_code": "644682655",
"telephone_number": "660-562-2525",
"fax_number": "660-562-7996"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2016 S MAIN ST",
"city": "MARYVILLE",
"state": "MO",
"postal_code": "644682655",
"telephone_number": "660-562-2525",
"fax_number": "660-562-7996"
}
],
"practiceLocations": [
{
"address_1": "4600 Valley Rd Ste 200",
"address_purpose": "LOCATION",
"city": "Lincoln",
"state": "NE",
"postal_code": "685104882",
"country_code": "US",
"telephone_number": "402-327-6921",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "WALLACE",
"first_name": "MIKAILA",
"credential": "DO",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2021-06-22",
"last_updated": "2025-05-12",
"certification_date": "2025-05-12",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "MO",
"license": "2024030678",
"primary": true
},
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "NE",
"license": "TEP9082",
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "200147246",
"state": "MO"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "470553011-00",
"state": "NE"
}
],
"endpoints": [],
"other_names": []
}Other providers in Maryville, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 12, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.