Provider Demographics
NPI:1003805904
Name:WOLF, ROBERT J (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:WOLF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:53 HUNTER RD
Mailing Address - Street 2:
Mailing Address - City:UXBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01569-1153
Mailing Address - Country:US
Mailing Address - Phone:508-779-0357
Mailing Address - Fax:
Practice Address - Street 1:1540 LAKE LANSING RD
Practice Address - Street 2:SUITE 107
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-3756
Practice Address - Country:US
Practice Address - Phone:517-913-3800
Practice Address - Fax:517-913-3901
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010733512085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1023349OtherMCLAREN HEALTH PLAN-COMMERCIAL
MI0M21440051OtherMEDICARE ADVANTAGE
MI1023349OtherMCLAREN HEALTH PLAN-MEDICAID
7721024OtherAETNA
MI4815847Medicaid
P00350809OtherRAILROAD MEDICARE
MI1023349OtherMCLAREN HEALTH ADVANTAGE
MI200000001052OtherPHP
MI200000001052OtherPHP FAMILYCARE
255189OtherPHCS
MI3003314351OtherBLUE CROSS BLUE SHIELD OF MICHIGAN/BLUE CARE NETWORK
P00350809OtherRAILROAD MEDICARE
MI200000001052OtherPHP