NPIMap

Individual provider Active NPI

Kevin Peter Scott Wallace, MD

  • Internal Medicine Physician
  • Menlo Park, CA
National Provider Identifier
1255309258
Registry record updated Apr 24, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
C151609 Issued in CA
Practice address
1300 Crane St
Menlo Park, CA 94025-4260
Phone
(650) 498-6500
NPI assigned
Mar 8, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Apr 24, 2024

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X C151609 CA Primary

Addresses

Primary practice location

1300 Crane St
Menlo Park, CA 94025-4260

Mailing address

1300 Crane St
Menlo Park, CA 94025-4283
Phone (650) 498-6649

Other identifiers 1

IdentifierTypeStateIssuer
0000992201MedicaidDE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20171026000792 CA Practitioner - Internal Medicine 8123082708 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Internal Medicine
Education
Other, 1988
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
University Healthcare AllianceGroup PAC ID 6305748799, 334 clinicians

Practice addresses (Care Compare)

1300 Crane St
Menlo Park, CA 94025-4260
Phone (650) 498-6500

Hospital & facility affiliations

  • Alphacare Home Health Home health agency, San Bruno, CA, CCN 559279
  • Meridian Home Health Home health agency, Newark, CA, CCN 059237
  • Stanford Health Care Hospital, Stanford, CA, CCN 050441

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
C151609CAMDInternal Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
University Healthcare Alliance Internal Medicine CurrentSince Nov 13, 2017 Accepting new patients
NYU Langone Hospitals Past Accepting new patients
Stanford Hospital and Clinics Past Accepting new patients
Affinity Medical Group Past Accepting new patients
Beebe Medical Center, Inc. Past Accepting new patients

Locations

1300 Crane St
Menlo Park, CA 94025
Phone (510) 785-5000

Interoperability endpoints

  • Direct secure messaging: kwallace198983@direct.stanfordhealthcare.org

Organizations & group practices 5

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.

Hospital & facility affiliations 9

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

NPI Registry JSON

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

{
    "created_epoch": "1141776000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1713916800000",
    "number": "1255309258",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1300 CRANE ST",
            "city": "MENLO PARK",
            "state": "CA",
            "postal_code": "940254283",
            "telephone_number": "650-498-6649",
            "fax_number": "650-326-7931"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1300 CRANE ST",
            "city": "MENLO PARK",
            "state": "CA",
            "postal_code": "940254260",
            "telephone_number": "650-498-6500"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "KEVIN",
        "middle_name": "PETER SCOTT",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-03-08",
        "last_updated": "2024-04-24",
        "certification_date": "2024-04-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "CA",
            "license": "C151609",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0000992201",
            "state": "DE"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Menlo Park, CA

Sources for this page

Verify at the official NPI Registry.