Provider Demographics
NPI:1316931728
Name:WOLF, EDWARD J (MD)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:J
Last Name:WOLF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64589
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4589
Mailing Address - Country:US
Mailing Address - Phone:410-602-7782
Mailing Address - Fax:410-602-2438
Practice Address - Street 1:1838 GREENE TREE RD
Practice Address - Street 2:SUITE 400
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-6391
Practice Address - Country:US
Practice Address - Phone:410-602-7782
Practice Address - Fax:410-602-2438
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0029606174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD395401300Medicaid
MDD73787Medicare UPIN
MD395401300Medicaid