Provider Demographics
NPI:1285948364
Name:MARK WOLF, MD, PC
Entity type:Organization
Organization Name:MARK WOLF, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATED
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-830-6697
Mailing Address - Street 1:2055 BLOOMFIELD WOODS CT
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-1915
Mailing Address - Country:US
Mailing Address - Phone:248-335-0537
Mailing Address - Fax:
Practice Address - Street 1:2055 BLOOMFIELD WOODS CT
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-1915
Practice Address - Country:US
Practice Address - Phone:248-335-0537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-02
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052955207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4408234271OtherBCBS
MI3521084Medicaid
MI0M71880Medicare PIN