1003805904 NPI number — DR. ROBERT J WOLF MD

Table of content: DR. ROBERT J WOLF MD (NPI 1003805904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003805904 NPI number — DR. ROBERT J WOLF MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOLF
Provider First Name:
ROBERT
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003805904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
53 HUNTER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UXBRIDGE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01569-1153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-779-0357
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1540 LAKE LANSING RD
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48912-3756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-913-3800
Provider Business Practice Location Address Fax Number:
517-913-3901
Provider Enumeration Date:
10/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  4301073351 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1023349 . This is a "MCLAREN HEALTH PLAN-COMMERCIAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0M21440051 . This is a "MEDICARE ADVANTAGE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1023349 . This is a "MCLAREN HEALTH PLAN-MEDICAID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 7721024 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4815847 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00350809 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1023349 . This is a "MCLAREN HEALTH ADVANTAGE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 200000001052 . This is a "PHP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 200000001052 . This is a "PHP FAMILYCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 255189 . This is a "PHCS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3003314351 . This is a "BLUE CROSS BLUE SHIELD OF MICHIGAN/BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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