Active NPI
Kacey L Wallace, DO
- Family Medicine Physician
- Chickasha, OK
National Provider Identifier
1306868534
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 4339
- Practice address
- 1000 W Choctaw Ave Ste 9
Chickasha, OK 73018 - Phone
- (405) 544-2940
- Fax
- (405) 337-9632
- NPI assigned
- Jul 24, 2006
- 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 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 4339 | OK | Primary |
Addresses
Primary practice location
1000 W Choctaw Ave Ste 9
Chickasha, OK 73018
Mailing address
1000 W Choctaw Ave Ste 9
Chickasha, OK 73018
Phone (405) 544-2940
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| P00331218 | Other | OK | MEDICARE RAIL ROAD |
| 200077860A | Medicaid | OK |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
- Opted out of Medicare
- Yes, effective Jul 22, 2022 through Jul 22, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Osteopathy
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Summit Medical Center | Past | Accepting new patients |
Interoperability endpoints
- kacey.wallace@133635819438084.direct.elationemr.com
Organizations & group practices 1
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.
-
- General Acute Care Hospital
- Edmond, OK
- NPI 1356574560
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1153699200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1700784000000",
"number": "1306868534",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1000 W CHOCTAW AVE STE 9",
"city": "CHICKASHA",
"state": "OK",
"postal_code": "73018",
"telephone_number": "405-544-2940",
"fax_number": "405-337-9632"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1000 W CHOCTAW AVE STE 9",
"city": "CHICKASHA",
"state": "OK",
"postal_code": "73018",
"telephone_number": "405-544-2940",
"fax_number": "405-337-9632"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "KACEY",
"middle_name": "L",
"credential": "DO",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-07-24",
"last_updated": "2023-11-24",
"certification_date": "2020-06-11",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "OK",
"license": "4339",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICARE RAIL ROAD",
"identifier": "P00331218",
"state": "OK"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "200077860A",
"state": "OK"
}
],
"endpoints": [],
"other_names": []
}Other providers in Chickasha, OK
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 24, 2023; 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; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.