Derrick I Wallace, M.D.

Primary specialty

Otolaryngology PhysicianTaxonomy code 207Y00000X

License

25MA08175200 Issued in NJ

Practice address

187 Washington Ave
Suite 2I
Nutley, NJ 07110-3935

Phone

(973) 235-0090

Fax

(973) 235-0090

NPI assigned

Nov 22, 2005

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in NJ

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Otolaryngology

Education

Icahn School of Medicine at Mount Sinai, 1996

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Summit Medical Group PAGroup PAC ID 5395642276, 1,204 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Hackensack Meridian Mountainside Medical Hospital, Montclair, NJ, CCN 310054
• Overlook Medical Center Hospital, Summit, NJ, CCN 310051
• Kessler Rehab Center Inpatient rehabilitation facility, West Orange, NJ, CCN 313025

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: derrick.wallace.1@2983.direct.athenahealth.com

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.

• Summit Medical Group PA

  • Multi-Specialty Clinic/Center
  • Berkeley Heights, NJ
  • NPI 1942254347
  Medicare reassignment Care Compare group NPD
• Summit Medical Group PA

  • Durable Medical Equipment & Medical Supplies
  • Hackensack, NJ
  • NPI 1043930555
  NPD
• North Jersey Ear Nose & Throat

  • Otolaryngology Physician
  • Belleville, NJ
  • NPI 1124105283
  NPD (past)
• River Oaks Management Company LLC

  • Family Medicine Physician
  • Jackson, MS
  • NPI 1922029040

  Otolaryngology

  NPD (past)
• St Lukes Hospital of Kansas City

  • Otolaryngology Physician
  • Kansas City, MO
  • NPI 1083658066
  NPD (past)
• Summit Medical Group, Inc

  • Family Medicine Physician
  • Erlanger, KY
  • NPI 1750343216
  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Ahs Hospital Corp.

  • General Acute Care Hospital
  • Summit, NJ
  • NPI 1740254143
  Care Compare affiliation
• Kessler Institute for Rehabilitation Inc

  • Rehabilitation Hospital
  • West Orange, NJ
  • NPI 1013919620

  Inpatient rehabilitation facility

  Care Compare affiliation
• Montclair Hospital LLC

  • General Acute Care Hospital
  • Montclair, NJ
  • NPI 1982720249
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1132617600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1322524800000",
    "number": "1114900362",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "187 WASHINTON AVE",
            "address_2": "SUITE 2I",
            "city": "NUTLEY",
            "state": "NJ",
            "postal_code": "071101980",
            "telephone_number": "973-235-0090",
            "fax_number": "973-842-0830"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "187 WASHINGTON AVE",
            "address_2": "SUITE 2I",
            "city": "NUTLEY",
            "state": "NJ",
            "postal_code": "071103935",
            "telephone_number": "973-235-0090",
            "fax_number": "973-235-0090"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "DERRICK",
        "middle_name": "I",
        "credential": "M.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2005-11-22",
        "last_updated": "2011-11-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Y00000X",
            "taxonomy_group": "",
            "desc": "Otolaryngology",
            "state": "NY",
            "license": "208988",
            "primary": false
        },
        {
            "code": "207Y00000X",
            "taxonomy_group": "",
            "desc": "Otolaryngology",
            "state": "NJ",
            "license": "25MA08175200",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "02237176",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• John L Volpe Jr., O.D.
• Vreeland Associates, LLC
• Evan J Waldron, MD/PHD
• Naftoli Y. Walfish, LCSW
• Walgreen Co
• Su-Lai Wang, NP
• Joseph Jihad Warren, PA
• Wayne a. Armenti DMD PA
• Samphena T Weah
• Yael Wedeck, LCSW

• Otolaryngology Physician in Nutley, NJ
• Providers in Nutley, NJ by specialty
• Otolaryngology Physician in New Jersey

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 29, 2011; 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.

Verify at the official NPI Registry.