Provider Demographics
NPI:1386791622
Name:WOLF, MARY MARGARET (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:MARGARET
Last Name:WOLF
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:50 INDUSTRIAL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013-1246
Mailing Address - Country:US
Mailing Address - Phone:269-427-7937
Mailing Address - Fax:269-427-5180
Practice Address - Street 1:800 M-139
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-4843
Practice Address - Country:US
Practice Address - Phone:269-927-5400
Practice Address - Fax:269-927-5493
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2016-02-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301095936207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0148138Medicaid
MTE64250Medicare UPIN
MT8653Medicare ID - Type Unspecified