1841373404 NPI number — COURTNEY E WOLF NP

Table of content: COURTNEY E WOLF NP (NPI 1841373404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841373404 NPI number — COURTNEY E WOLF NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOLF
Provider First Name:
COURTNEY
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PORTER
Provider Other First Name:
COURTNEY
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1841373404
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 778912
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-8912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-777-6435
Provider Business Mailing Address Fax Number:
317-777-6644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 N RITTER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46219-3027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-274-4779
Provider Business Practice Location Address Fax Number:
317-948-9806
Provider Enumeration Date:
10/24/2006

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: 363LN0000X , with the licence number:  28154359 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LN0000X , with the licence number: 71002062A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P01221391 . This is a "RR MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000589162 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200515470 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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