1609166156 NPI number — JEFFREY C WOLFE MT-BC

Table of content: JEFFREY C WOLFE MT-BC (NPI 1609166156)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609166156 NPI number — JEFFREY C WOLFE MT-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOLFE
Provider First Name:
JEFFREY
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MT-BC
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:
1609166156
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4566 BAYWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44212-5502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-808-0859
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2008 DEMPSTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANSTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60202-1017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-905-1500
Provider Business Practice Location Address Fax Number:
847-251-5391
Provider Enumeration Date:
04/18/2011

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: 225A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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