Provider Demographics
NPI:1063596674
Name:WOLF, MYRON I (DPM)
Entity type:Individual
Prefix:
First Name:MYRON
Middle Name:I
Last Name:WOLF
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BIESTERFIELD RD STE 204
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3361
Mailing Address - Country:US
Mailing Address - Phone:847-437-7377
Mailing Address - Fax:847-437-7388
Practice Address - Street 1:800 BIESTERFIELD RD STE 204
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3361
Practice Address - Country:US
Practice Address - Phone:847-437-7377
Practice Address - Fax:847-437-7388
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004461213E00000X
ILIL016004461213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1604829OtherBCBS
IL979971Medicare PIN
U33104Medicare UPIN
IL1604829OtherBCBS