Provider Demographics
NPI:1043439193
Name:RANDY L WOLFE, MD
Entity Type:Organization
Organization Name:RANDY L WOLFE, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-688-4325
Mailing Address - Street 1:PO BOX 1395
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42302-1395
Mailing Address - Country:US
Mailing Address - Phone:270-688-4325
Mailing Address - Fax:
Practice Address - Street 1:1325 TRIPLETT ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3163
Practice Address - Country:US
Practice Address - Phone:270-688-4325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18397207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65934259Medicaid
KY1879601Medicare PIN
KY65934259Medicaid